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SCIATICA
SCIATICA
A FRESH STUDY
BY
WILLIAM BRUCE, M.A., LL.D., M.D. (Aber.)
WITH NOTES OF NEARLY 700 CASES
NEW YORK
WILLIAM WOOD & COMPANY
MDCCCCXIII
'C
Y
Z JUL 18^9^5 -
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5n /llbemoiiam.
PROFESSOR PETER REDFERN,
OF BEI.FAST,
QUONDAM LECTURER ON ANATOMY, KING's COLLLEGE
AND UNIVERSITY, ABERDEEN ;
ALEXANDER KILGOUR, m.d.,
PHYSICIAN, ROYAL INFIRMARY, ABERDEEN ;
AND
WILLIAM ANDERSON GAVIN, m.a., l.r.c.s.e.,
STRICKEN, ABERDEENSHIRE ;
WHO TAUGHT ME THE RUDIMENTS OF ANY
SMALL KNOWLEDGE I POSSESS OF THE
SCIENCE AND ART OF MEDICINE.
PREFACE
With considerable diffidence, but with implicit
belief in the truth of the views as to the real
pathology of sciatica which I shall endeavour to
explain, I present this short treatise to the atten-
tion of my medical brethren. I am well aware of
the difficulties I shall have to encounter in trying
to convince them that the current explanation of
the symptoms of the disease is wrong, and the
one which I suggest right. Heresy must ever be
unpopular. The human mind, once broken loose
from its accustomed moorings and tossed about
on the wide waters of discussion, may drift any-
where. A new pathology necessarily implies a
different line of therapeutic application, and treat-
ment from a fresh standpoint. It naturally tends
to demolish well-established indications, and to
unsettle the ideas of the ordinary steady-going
practitioner and consultant. The iconoclast must
be wary of attempting to break down accepted
theories as to the essential nature of the disease
he is discussing, unless he can show on solid
vii
viii PREFACE
substantial grounds the reason for his faith.
And, further, he is sure to be met by the
objection : '* Your views are correct enough as
regards a certain limited class of cases, but they do
not cover the whole ground. Your explanations
are sufficient so far, but they account only for
a small number of selected examples of the com-
plaint you are asking us to consider."
Moreover, I cannot claim to have entered on
this investigation with an altogether unprejudiced
mind. I doubt if, on inquiry as to facts, any
of us can quite be sure to have his mental field
of vision a tabula rasa. All I can say is, I
have striven to give an impartial account, as
far as it goes, of my observations, leaving nothing
out and adding nothing to the real facts as detailed.
Though I claim to found my deductions on more
than a thousand observed cases of sciatica, I am
free to confess the evidence does not entirely con-
firm my conclusions. I may safely say, however,
that the history of the cases of which I have
records does go a long way towards such proof.
I do not arrogate to myself special claims for
more wisdom than my neighbours. But I may
remind my critics that, in the course of a long
professional life, to quote a few outstanding in-
stances, I have seen typhus and typhoid placed
in separate categories ; Addison's disease imported
PREFACE ix
into our nomenclature ; and appendicitis, as a
special complaint, fully recognized and systemati-
cally looked for.
I venture, then, to plead for a careful study
of the physical evidence of sciatica. I have no
doubt the result of such investigations will sooner
or later — it may be rather late than soon — confirm
the truth of the opinions held by the present
writer.
I am glad to take this opportunity of expressing
my sense of the obligations I owe to many kind
friends in connection with this attempt to explain
my views on sciatica. In particular, I wish to
mention the names of Drs. Galbraith and Middle-
ton ; Professor Robert Reid and Dr. Calder ; my
brother, Dr. Mitchell Bruce, London (for his final
revision of the context) ; my sons Alexander and
William ; and especially Mr. Watt, who has revised
the text and corrected the proofs. 1 have also
gratefully to acknowledge the kind permission of
the editors of the Lancet to make any use I thought
proper of an article by me as published by them
on August 22, 1903.
I am also indebted to Messrs. Churchill for a
similar favour in connection with the work of
Dr. Lawson, and specially to the veteran Sir William
Gowers for his leave to make such extracts from
his writings as I cared to quote.
X PREFACE
With regard to the long tale of cases in
Appendix II., after much deliberation I have
thought it best to give a list which includes every
single case I have met with since my attention
has been specially directed to the subject of
sciatica.
On the other hand, I quite recognize the want
of negative evidence. I have, so to speak, put all
my cards on the table, so that an impartial student
may have a full opportunity of seeing for himself
the evidence on which I have been led to the
conclusion as to the true pathology of sciatica.
The ultimate verdict I leave, with full confidence,
to the judgment of the profession.
WILLIAM BRUCE.
Dingwall, N.B.
August, 191 3.
CONTENTS
CHAPTER I
HISTORICAL SURVEY
SIR W. GOWERS' VIEWS -
DR. LAWSON's book
VARIOUS MEDICAL THEORIES
PAGE
I
2
12
26
CHAPTER U
MY OWN THEORY - - - "32
HILTON ON " REST AND PAIN " - - "33
METHODS OF EXAMINATION - - - 42
THE SCIATIC NERVE - - - "44
PROFESSOR REID ON THE NERVOUS ARRANGEMENT
OF THE HIP-JOINT - - - - 45
CASES TABULATED - - - - 46
DIAGNOSTIC RESULTS - - - - 48
DR. IRONSIDE BRUCE ON X RAYS IN SCIATICA - 58
CHAPTER III
TREATMENT OF SCIATICA
71
APPENDICES
I. ANATOMY OF SCIATIC NERVES
II. CASES - - -
BIBLIOGRAPHY - - -
79
89
174
XI
SCIATICA: A FRESH STUDY
CHAPTER I
HISTORICAL
THE^term " sciatica " implies that the complaint
we are considering is connected with particular
nerves — viz., the greater and lesser sciatic. I
have therefore thought it advisable, in order to
help my readers to follow the discussion as to the
precise nature of the disease, to give an account of
these nerves, with illustrations, supplied to me
by my friend, Dr. Calder, Assistant Professor of
Anatomy in the University of Aberdeen. (See
Appendix I.)
In dealing with my subject, I shall, by way of
introduction, proceed to give a resum6 of the
views of the best-known authors who write upon
it, and shall begin with Sir William Gowers, the
acknowledged chief authority on diseases of the
nerves, of which sciatica, as the name implies, is
almost universally believed to be one.
2 SCIATICA : A FRESH STUDY
The following is Sir W. Gowers' account of sciatica,
somewhat abbreviated (" Diseases of the Nervous System,'^
third edition, 1889, p. loi) :
"As the word * sciatica ' is commonly used, it is a general
designation for all affections of which the chief symptom
is pain in the region of the sciatic nerve. In a stricter use
of the word, however, it is applied to painful affections of
the nerve not due to any morbid process outside it ; thus
limited, it practically corresponds to inflammation of the
nerve. Two varieties may be distinguished, however^
according as the process in the nerve is excited by primary
disease in its vicinity: 'secondary' sciatica, and 'primary'
sciatica, when the pain is the expression of disease beginning
in and relating to the nerve itself. Primary sciatica is
sometimes regarded as a neuralgia. This view is, in the
main, erroneous ; the vast majority of cases of sciatica are
really cases of true neuritis.
" Underlying most cases of sciatica is cither the state of
definite gout or that rheumatic diathesis in which the
fibrous tissues suffer, especially those that are connected
with the muscles — a form closely connected with common
gout by co-existence or descent. It occurs frequently in
those who are themselves gouty, who present the personal
characteristics of the disease, and have fostered it by their
mode of life. It occurs also in those of gouty inheritance,,
but who themselves have been abstemious, and sometimes
present a weakly constitution — thin, pallid, neurotic. The
latter have often suffered from acute articular rheumatism
in earlier life.
" It is among them that the most severe cases are met
with, in which the inflammation spreads to other nerves,
or involves the sheath of the sciatic with other structures,,
HISTORICAL 3
and that it develops early in life — during, for instance, the
second fifteen years. This constitutional state, with all
its effects, is sometimes met with when there is only
trifling evidence of inheritance. Some unknown influence
seems to determine its development in intense degree as a
congenital tendency, manifested by rheumatic troubles,
various and severe, early in adult life — the sporadic occur-
rence of that which is usually inherited. There is no
evidence of a direct causal relation to other constitutional
diseases. Syphilis has been supposed in some cases to give
rise to it, but the cases are rare, and the common cause
can seldom be excluded.
"An exciting cause is to be traced in many of the cases.
Exposure to cold is the most frequent. It is usually loca
exposure, as by wet boots, standing in water, etc. ; some-
times, however, a general chill of the body determines an
attack. The exposure to cold may be even more direct,
as by sitting on wet grass. Draughty water-closet seats
are answerable for some cases. The neuritis often arises
by the extension of an adjacent rheumatic affection of the
fibrous tissue, especially of that form of * lumbago ' which
involves the fibrous attachments of the muscles at the
back of the sacrum, less commonly in its ordinary lumbar
seat. This affection passes down from the sacrum, ex-
tending along the fasciae, to the nerve sheath in the
neighbourhood of the sciatic notch ; or passes forwards,
over the crest, to the front of the iliac bone, and spreads
in the tissues above the lumbar plexus, and descends to
that which covers the mass of sacral nerves from which
the sciatic proceeds. (The fact is of much interest,
because it shows that this form of fibrous rheumatism, of
which we have only a very vague pathological conception,
4 SCIATICA : A FRESH STUDY
must be regarded as inflammation, since positive neuritis
results from it.) The rheumatic pain has usually existed
for a few days only before the extension occurs ; but some-
times a chronic affection, after existing as such for several
weeks, spreads acutely.
" Mechanical disturbances sometimes excite the disease,
and often co-operates with other influences. The pressure
of the edge of the chair, in those who sit much, is the
most frequent. Muscular over-exertion, suddenly com-
pressing the nerve in the thigh, is occasionally effective.
If the nerve is already tender, a strong contraction of the
muscles in the back of the thigh, especially when the knee
is flexed and the muscles can freely shorten and widen,
may produce acute pain in the nerve, evidently by its
compression. This cause is probably effective only in a
predisposed person, or when there is already commencing
neuritis.
"'Various morbid processes within the pelvis may cause
sciatica by compressing the sacral plexus, or by exciting
inflammation, which invades the nerve. Rectal and other
tumours give rise to progressive pressure, and the inflamma-
tion excited descends the nerve, resembling the primary
form. It may be an early symptom of a growth springing
from the bone, as an enchondroma arising at the sacro-
iliac synchondrosis. Pelvic inflammation and injury during
labour are occasional causes. A loaded rectum may be
the excitant, but is a rare cause, although apt to be
recurrent when once effective. Lastly, the sciatic nerve
may be secondarily involved in mischief that is outside the
pelvis. The most frequent cause of this is disease of the
bone, as disease of the hip-joint, especially senile rheumatic
inflammation.' (Gibson.)
HISTORICAL 5
" The proclivity of the fibrous tissue of this nerve to
suffer primarily is due to its position and the exposure
this involves, and to its connections, which facilitate the
passage of inflammation to it. But there are cases with a
strong disposition for fibrous rheumatism to fix itself in the
tissues of the pelvis, sacral, and lumbar regions ; the
nerves cannot escape implication. Whether the sciatic
suflFers early or late, in what degree, depends on secondary
conditions ; but it is specially liable on account of the
anatomical relations of its origin. The mass of the
' sacral plexus ' is prolonged into it, and the membranes
covering this and its branches, including the lumbo-sacral
cord, are very liable to be the seat of such inflammation,
widespread, fixing itself irregularly on the various lierves,
but in special degree on the sciatic. In these cases the
pain is extensive and often severe in the front of the
thigh, but the symptoms of descending neuritis are promi-
nent chiefly in the sciatic."
Symptoms. — The two nerves suflFer with nearly equal
frequency, but Gibson found, in his extensive series, that
the left was a little more liable, in the proportion of
48 to 44 per cent. In about 7 per cent, both were
affected simultaneously — a striking indication of the smaller
relative part played by the general blood-state compared
with polyneuritis and the preponderant influence of local
excitants. The chief symptom of primary sciatica is pain
along the course of the nerve trunk, often also along that
of its branches. Pain in the area of its distribution is
sometimes subsequently developed. The affection may
begin suddenly, especially in cases of rheumatic origin —
as suddenly as lumbago. Some movements seem to excite
but there has usually been slighter rheumatic pain in
6 SCIATICA : A FRESH STUDY
the neighbourhood for a day or two, generally about the
hip or sacrum. More frequently the onset is gradual ;
slight pain is felt along the back of the thigh, on move-
ments and in postures that make the nerve tense or cause
pressure upon it. This pain, due to a slight degree of
inflammation, has generally existed for some weeks, in-
creasing in degree until a considerable severity is attained,
or suddenly becoming intense under the influence of some
exposure or over-exertion. At last the patient is easy only
when at rest, and when the leg is in a certain posture.
Any movement that makes the nerve tense causes pain,
and to avoid this the knee, in walking, is kept slightly
flexed, and the leg held stiflfly so as to avoid stretching the
nerve. As the pain on movement increases, spontaneous
pain is added, at first chiefly felt in the nerve trunk, but
soon spreading to its branches and distribution. It is
usually most intense in certain parts — (i) Above the hip-
joint, near the posterior iliac spine ; (2) at the sciatic
notch ; (3) about the middle of the thigh ; (4) behind the
knee ; (5) below the head of the fibula ; (6) behind the
external malleolus ; (7) on the back of the foot. The
pain may radiate over the whole distribution of the nerve,
but it is often so distinctly limited to the course of the
trunk and branches that the patient points these out with
exactness when he indicates its course. The chief inten-
sity of the pain is usually down the back of the thigh. It
may be dull or acute, is often burning in character, and
v/orse at night. It may seem to dart downwards, starting
from the highest point. As the pain on movement in-
creases, the nerve trunk becomes extremely tender to
pressure. Even before the tenderness becomes consider-
able in the thigh, pain may often be produced in the
HISTORICAL 7
following manner : Let the patient lie on a chair, with the
knee at a little more than a right angle, and the body bent
forward, so as to lengthen the course of the nerve at the
hip- and knee-joints. If the finger is then pressed into
the popliteal space, so as to make the nerve a little more
tense, a pain is felt in the course of the nerve at the back
of the thigh, or above the sciatic notch, and behind the
hip. It is due to the sensitiveness of the nerve to tension,
and is a very useful test, especially when the part inflamed
is high up within the pelvis. It may reveal the affec-
tion of the nerve here, by making it more tense, when
there is no tenderness to pressure at the back of the
thigh.
" Abnormal sensations other than pain are often felt in
the area of distribution of the nerve — tingling, formica-
tion, and the like ; and in severe cases there may be
diminished sensibility on the back of the thigh, on the
leg or the foot. The affection of sensibility at the back
of the thigh indicates that the disease extends up the
nerve, above the sciatic notch, to the origin of the small
sciatics, or that this is involved in a simultaneous neuritis.
In severe cases the muscles supplied by the nerve become
flabby, tender to the touch, and sometimes distinctly
weak and wasted. This is chiefly noticeable in the calf
muscles and in the group supplied by the external
popliteal nerve. A tendency to cramp in the muscles is
often very marked. There may be an alteration in the
electrical irritability, usually a slight increase to each
form if it is considerable, and amounts to a distinct
degenerative reaction only in very severe cases. Slight
fever and corresponding constitutional symptoms may
attend an onset that is acute, when the inflammation is
8 SCIATICA : A FRESH STUDY
intense. Chronic cases, however, are usually not attended
by elevation of temperature.
"The duration and severity of the affection are
extremely variable. They depend on its intensity and
on the amount of rest given to the limb in the early
stage, and on the constitutional state of the patient.
The inflammation may be trifling in degree, causing pain
on movement only, which may pass away in the course of
a few weeks. On the other hand, the spontaneous pain
may be so continuous and intense that sleep can be
obtained only by the help of narcotics, and the disease
may continue for many months, and even for a year.
In most cases that last more than a year there is partial
recovery and relapse. Improvement is shown first by
the subsidence of spontaneous pain, followed by the slow
diminution of the pain on movement, and then of the
tenderness of the nerve. The muscular wasting, which
occurs in severe cases, may last long after the active stage
is over ; fibrillary contractions in the muscles that have
been affected may continue for years, and are often
accompanied by a strong tendency to cramp, which may
be excited by voluntary contraction. Occasionally a
secondary neuralgia is set up, which may be very
enduring, may involve the entire length of the nerve,
and may be wide in distribution, extending outside the
sciatic area.
"The disease is prone to relapse, and still more prone
to recur after recovery. A second attack may occur in
the same or in the other leg, but both legs are scarcely
ever affected at the same time. At last the tendency of
the sheath to be inflamed seems to become exhausted, and
the liability to relapse to cease.
HISTORICAL 9
" The cases of secondary sciatica, depending on disease
outside the nerve compressing or irritating it, differ, in
some respects, from the primary form. The early pain
is felt less in the nerve trunk than in its distribution,
especially when the nerve suffers first by pressure ;
interference with the conducting functions is more
conspicuous in the early stage. The primary form may
be afterwards closely sim.ulated, because secondary in-
flammation may descend the nerve and induce the same
tenderness of the nerve trunk. The course of the
secondary cases is mostly progressive, but it depends on
that of the original disease."
Sir William Gowers insists that sciatica is
essentially a neuritis, believing that, as a rule, the
disease first attacks the muscular and fibrous
structures, and then spreads to the sciatic nerves.
The mischief, he says, is usually due to the bad
effects of local colds, as by sitting on wet grass
or on draughty water-closet seats. He goes on
to state that muscular over-exertion compresses
the nerve in its course ; various swellings in the
pelvis, he considers, lead also to pressure on the
nerve, such as retained faeces or fibrous rheuma-
tism, already spoken of, by implicating the mass
of the sacral plexus. He allows that some move-
ments develop the pain, and makes much of the
presence of special points in the course of the
nerve which show tenderness on pressure. Finally,
he quotes some second-hand evidence of the morbid
10 SCIATICA: A FRESH STUDY
anatomy of the disease. A careful study of his
views must, I humbly think, lead an unprejudiced
mind to the conclusion that they do not rest on
solid pathological grounds. Are there any really
settled facts to prove that there is here a genuine
" neuritis " ? Gowers' account of the state of the
nerve as observed during operations is very vague,
and surely not sufficient to warrant a complete
and satisfactory pathology. Then, again, granting
the presence of fibrositis, is it not more likely
that this degenerative process is the result of the
diseased action rather than its cause ? It is not
easy to see how this condition, when formed, is
likely to spread to the nerve.
One well may be very doubtful of the supposed
bad effects of local cold, etc. I have the best
anatomical authority for asserting that the sciatic
nerve is carefully and abundantly protected from
such injuries. We must remember that the lay
mind is too prone to accept such probable ex-
planations. Its mental horizon in judging the
relation between cause and effect is necessarily too
limited to be trusted.
Again, Sir William Gowers' confident statements
as to compression of the nerve by certain violent
muscular actions are not at all convincing. On
the face of it, they are highly unlikely to be
correct. It is almost an insult to Nature to sup-
HISTORICAL 1 1
pose them to be true. While, for reasons which
we shall see farther on, certain movements cause
pain in the nerve ; yet, on the other hand, pain
with the limb at rest is often very decided.
Here also I wish to point out that experiments
on the cadaver prove that only extreme flexion
of the hip-joint causes any stretching of the
nerve.
Reverting to the question of neuritis, and
Gowers' reference to certain definite points which
show tenderness on pressure, I am quite willing
to allow he may be correct when he says these are
common ; I have rarely found the tender points
of the books, and as a rule I have searched
for them. There need be no doubt that
irritation steadily passing along the trunk of a
nerve may in time cause some form of temporary
inflammation or a " neuritis " of a kind. But
I say again, Where did this irritation originate ?
That is what has to be settled.
Further, it is allowed that the reaction of
degeneration in the muscles is very uncommon.
In histories of attacks of sciatica, likewise, there is
no evidence of permanent disability of the nerve
(unless it has been stretched purposely), and
improvement in the symptoms is often rapid and
generally complete, which is surely unlikely if
the inflammation of the nerve structures has
12 SCIATICA: A FRESH STUDY
been at all protracted so as to produce a genuine
neuritis.
Dr. Lawson in his book ("Sciatica," etc., second
edition, 1877, part i., p. 3) says :
" The history of sciatica is, it must honestly be con-
fessed, the record of pathological ignorance and of
therapeutical failure. It presents to us a blurred page
whereon we find traced the results of confused reasoning,
incomplete generalization, hasty observation, and un-
philosophic methods of treatment. From the circum-
stance that the affection itself is rarely fatal, it has failed
to arrest the entire attention of the great masters of our
art, and because of the fact that the patient who is
afflicted with it loudly demands relief, its treatment has
seldom been pursued with that persistence in any one
remedy which is so essential to the drawing of just and
reliable conclusions. Being a disease in which a
symptom is essentially the leading feature, so far at least
as our knowledge yet extends, it has been often con-
founded with other maladies, such as rheumatism and
morbus coxae, and, being connected with a supposed
degenerate condition of the nerve trunks, it has been,
with questionable justice, grouped with that vague class
of diseases — neuralgia. Hence the reason why we so
often hear of obstinate sciatica ; for it cannot be hoped,
so long as no definite method is followed in either the
study or the treatment of disease, that much in the shape
of useful therapeutical result is likely to be achieved.
" In sciatica, more, perhaps, than in any other malady of
equal gravity, therapeutists, it seems to me, have erred in
not confining their treatment to the simple phenomena of
HISTORICAL 13
the disease. Notwithstanding the one or two autopsies
which are reported in our annals, and which throw a
very uncertain light on the pathology of sciatica, in-
dicating that there is an alteration of the neurilemma of
the nerve, I think it will be admitted by those who wish
to see medicine based on a solid foundation of fact,
that there is no convincing evidence as to the actual
state of the sciatic trunk in this affection. I do not fear
any contradiction in asserting that even now we know
nothing of the pathology of sciatica. It is clear, then,
that if this be so, any special line of treatment on a priori
grounds of this kind has the doctrine of chances quite
against its success. To my mind, it is no less clear that,
in reference to etiology of sciatica, we experience nearly
an equal difficulty in laying down anything like a clear
and comprehensive statement. And this, I opine, is true,
whether we regard the disease from the standpoint of
sex, age, temperament — if I may be permitted the
expression — state of nutrition, or occupation of the
sufferer. I am disposed to conclude provisionally, from
a large number of cases, that sciatica is a somewhat special
affection, and that its only relation to what are generally
regarded as neuralgic diseases, such as the tic douloureux,
etc., lies in the circumstance that in the two cases pain in
the direction of nervous trunks is experienced, for in
neither origin nor character of pain, nor in the results
of treatment, can I see much to warrant the association of
sciatica with what is generally known as * facial neuralgia.'
" To be brief, the simple fact that all we really know
of sciatica — to wit, that it is a pain in the course of the
sciatic nerve — has been ignored is the reason why the
disease has been so long deem.ed incurable.
14 SCIATICA: A FRESH STUDY
" In describing the general characters by which the
affection may be recognized, it is as well to begin with
those which force themselves on the attention of the
patient, and which are sometimes called * symptoms.' I
prefer to speak of the features of the disease in this way,
as I think the term * symptoms' has many objectionable
qualities which render it inexact ; and I have no desire to
coin a new word, seeing the lamentable superabundance
of unprecise technicalities with which the accepted
terminology of medicine hampers scientific progress.
The indications, then, of disease which manifest them-
selves to the patient are primarily pain, stiffness, soreness
or tenderness on motion or pressure ; loss of muscular
power, permanent contraction of limb, coldness of surface
and apparent anaesthesia, may all or any of them subse-
quently present themselves in cases of true sciatica ; but
pain is the chief, and, in acute cases, generally the sole
peculiarity. In most works in which sciatica is dealt
with it is included under the head of neuralgia, and the
general description of the pain is one of those specializa-
tions which are so much to be regretted. Writers have
had before their minds the type of neuralgia proper — tic
douloureux — and out of this special form they construct
the definition of sciatic pain. I call attention to this
because it is not only an error in fact, but because it leads
often to mistaken diagnosis. It is not at all true, save in
rare cases, that the pain of sciatica is intermittent in the
accepted sense of the word ; nor is it correct to say, as
some writers do, that it is a sharp, acute, thrilling pain,
like that of facial neuralgia. It is nothing of the sort.
The pain in sciatica is, in bad cases, of great severity, but
it is a constant, heavy, absorbing pain ; a pain on which
HISTORICAL
15
the mind of the patient is unceasingly fixed ; a pain
which renders any prolonged posture quite impossible, and
which is relieved, but only temporarily so, by change of
position, and most distinctly, when the patient is recum-
bent, by flexing the whole limb. It is not a pain which
compels the patient to rush from one side of his chamber
to another in a state bordering on frenzy ; but it is one
which makes him peevish and irritable, which precludes
him from any continuous occupation, whether of work or
pleasure, which is, so to speak, perpetually gnawing at
him, and which completely deprives him of appetite. It
is a pain which, as the patient will tell you, runs along
down the thigh — in one or two cases I have seen the
direction reversed — but if you question him you will find
that its course is not the rapid, darting, shooting current
of neuralgia, but is simply a pain which extends with
m.oderate rapidity from one point to another. But it is
always a constant pain. It will often be found that
it is severe to a degree that is intolerable, and sometimes it
may seem even unendurable ; but these alterations, if they
exist at all, will be found most irregular, and they are
most commonly absent. As to the starting-point of the
pain, there is no rule to be laid down. Mostly the upper
portion of the sciatic is the part complained of, but now
and then the pain is at first located in the knee, or even
in the ankle or calf, and sometimes it begins almost at the
ischiatic notch. In all cases, however, of pure sciatica, it
is sure to be found after a while distinctly along the
course of the sciatic nerve, beginning at a point about
midway between the sacro-iliac synchondrosis and the
great trochanter, and extending along the outer side of the
thigh to the knee-joint. It may at first seem to the
1 6 SCIATICA: A FRESH STUDY
physician, from the replies of the patient, that the pain is
worse at night, but a little careful observation will dispel
the idea. I would dwell on this point, because in a large
number of gonorrhoeal and syphilitic cases the pains are
decidedly more ' racking ' at night than in the daytime,
and should be distinguished from those of sciatica, if only
for the reason that they are relieved by iodide of potassium,
while the pain of sciatica certainly is not. I have, indeed,
seen a case of sciatica rendered materially worse by the
administration of the iodide, which was given on a con-
fused notion of the pathology already alluded to. It will
soon be learned, at least from an intelligent patient, that
the circumstances of his being left to the sole contempla-
tion of his sufferings is the reason why the pain appears
greater at night. If he lies down on a sofa during the
daytime and tries to sleep, he will, as might be imagined,
complain that his pain is worse than it was before while
he was even partially diverted by conversation. If the pain
has existed for several days, the patient will be found
much lamed, and probably will be compelled to use a
stick in walking. He will complain of pain in moving
the limb, and will be found walking on the toes in order
to admit of that flexion of the limb which appears to give
relief Should this state of things have continued for a
fortnight or so, the flexion will have become permanent,
extension will have become impossible on the part of the
patient, and forcible extension will be attended with much
pain. If the case be an old chronic one, extension can
only be effected gradually. Any attempt to straighten
the limb would, I feel assured, be attended with rupture
of tissue of a serious nature.
" Besides this peculiar pain — which, by the way, unlike
HISTORICAL 17
that of facial neuralgia, comes on at first somewhat
gradually, and by no means very severely — and the lame-
ness already described, there are various other characters,
which, though unperceived by the patient, are perceptible
enough to the physician. These are tenderness of par-
ticular parts on pressure, wasting of the muscles, coldness
of the surface of the extremity, slight anaesthesia, and, in
very rare instances, possibly complicated with other nervous
diseases, hyperaesthesia also.
"Of all these the most frequent, as they are the most
readily recognized, are the tenderness and the wasting.
Whatever may be the significance of tender points over
the vertebrae in neuralgia proper, it must be confessed
that in sciatica as a rule this tendency to exhibit spinal
points of tenderness is not shown. In some few cases,
where the pain is almost confined to the upper third
of the nerve, and where the most sensitive part is ap-
parently the point of exit, there certainly is found tender-
ness in a well-marked degree over certain lumbar and
sacral vertebrae. In the majority of cases, especially where
the disease has not had a career of many months' duration,
no vertebral sorenesss or * tenderness on pressure ' can be
detected. But it seldom happens in decided cases of this
disease, in which the pain has lasted for some days, that
tenderness in the direction of the nerve does not exist. If
the physician follows out the course of the nerve from
above downwards, pressing firmly with his thumb, he will
soon come to a point where the patient cries out that he
is * hurt !' As I have already said, this will commonly
be in the upper third of the course of the nerve, and will
lie along a line of from 2 to 4 inches. In some cases
however, and particularly in those of long-standing, the
2
i8 SCIATICA: A FRESH STUDY
whole course of the nerve will be found very tender on
pressure.
" Wasting of the limb is only found in protracted cases,
where there has been lameness for a long time. In these
it is exceedingly distinct. It is necessary to bear in mind
the fact that atrophy is the sequel to disuse of the limb,
because it helps us to avoid some of those enticing but
dangerous speculations anent the relation of the nutrition
of the limb to the condition of the nerve. I have no desire
for a moment to deny that the nutrition of the muscles of
the thigh may be dependent on the influence of the sciatic
nerve ; but I think it is more in consonance with physio-
logical fact and clinical experience to regard the nutrition
of the muscle as the concomitant condition of its exercise.
In cases of sciatica with lameness, the muscles, sometimes
for a whole year or more, are allowed to fall into disuse,
and they waste away. In other cases of sciatica there is
no wasting worth mentioning. The question is one
of no mean import, since the hypothesis to which I
object is urged in support of one still more visionary
— viz., that sciatica is an affection of the central nervous
system.
" Leaving theory aside, it will be seen in well-marked
cases that there is very great flattening of the buttock of
the affected side, and the whole of the flesh of the thigh
will be seen flabbier and distinctly thinner and less rounded
in outline than that of the healthy limb. The patient
should be made to lie upon his belly, and the difference
between the two sides will then be apparent almost at
a glance. In cases in which the wasting has not advanced
very far, the first thing which will strike the eye of the
observer is, not the diminution of the muscle, but the
HISTORICAL 19
apparent increase of the bony prominences, and especially
of the sacro-iliac synchondrosis (a point of the utmost
importance in diagnosis, as I shall show when on that
part of the subject) ; but a little trouble in comparing the
' processes ' and handling the flesh on both sides will
leave no doubt in the mind of the physician.
" Anaesthesia is also a sign of the disease present in cases
of some duration. It is never marked in pure cases to any
absolute extent, but if we take compass points and com-
pare the cutaneous sensibility of the two limbs, we shall
obtain a well-drawn balance of sensibility on the part of
the unaffected thigh. This indication is, if I mistake not,
also urged by * central mischief theorists in support ot
their doctrine, but I cannot see upon what grounds it is
employed ; there is clearly diminished circulation in the
whole limb, for reasons already stated, and I think we
have in this condition a sufficient explanation of the
phenomenon without evoking the grave hypothesis of
degeneration of structure in the cord.
"It may be objected to the employment of the term
' natural history ' of a disease that it is too general, since
it should include the symptoms and pathology of the affec-
tion as well as the circumstances accompanying them.
On the other hand, the expression * etiology ' appears
equally unsatisfactory. I trust, therefore, that I may be
excused for treating of the questions included usually
in these divisions under the heading of the general condi-
tions of the malady.
" Sciatica being a disease of an essentially local character,
the bodily circumstances which are its companions are of
a very varying nature. Hence it is difficult to determine
those which are constant. It is, however, possible to
20 SCIATICA : A FRESH STUDY
indicate a few of the more regular conditions under which
the disease occurs ; and, firstly, as to age. It is, I think,
tolerably accurately laid down in most of our treatises that
sciatica is a disease from which the young possess an almost
absolute immunity. It is essentially an affection which
attacks persons between twenty and sixty. Nevertheless,
I have met with one case of pure and well-marked sciatica
in a boy of fourteen, who was addicted to aggravated
habits of masturbation. But such cases are extremely
rare, and the limits stated will be found to be correct in at
least nine-tenths of the cases of sciatica pur et simple. It
is not so easy to say whether it is more frequent in the old
than in the adult or middle-aged ; but if we take the age
of forty as the pivot of the scale, it will be observed that
the majority of instances occur between twenty and forty,
and the minority between forty and sixty. Sex presents
another determining condition of sciatica. Women are
far less subject to this affection than men : I should say
pretty nearly in the ration of i to 3. The type of female
constitution in which sciatica is oftenest met with is, in
the case of younger women, that which may be styled
the * leucorrhoeal.' Patients suffering from disordered
menstruation of various kinds, accompanied by the
* whites,' occasionally contract sciatica, and I have not
found that the removal of the menstrual condition relieves
the pain in the direction of the nerve. Under a course of
chalybeates and proper injections the case usually gets
well, quoad menstruation, and the general health is im-
proved, but the sciatica remains. Another type is that so
familiar to those who have charge of out-patients at our
hospitals. I refer to the sallow, shrivelled-faced, bright-
eyed and flatulent old tea-drinkers. These occur es-
HISTORICAL 21
pecially among the Irish population ; they eat little more
than a few pieces of bread in the twenty-four hours, but
they take tea (or, rather, a decoction of the leaves) three,
and sometimes four, times a day. These people are
sometimes seized with sciatica, and they constitute very
troublesome cases.
" As to mental state, I can certainly offer no personal
observations of a positive character. Intelligent and stupid
people seem alike liable to the disease. Something has
been vaguely written concerning the association of sciatica
with central mischief, but, as I have stated (ante) I
apprehend that this is an assumption purely gratuitous, and
certainly unwarranted by fair induction. If we exclude
from our consideration those obscure pains which accom-
pany disease of the central nervous system, and which are
certainly not sciatica as I understand it, then there is no
justification for the opinion that there is central nervous
mischief in this disease.
" Inheritance is a condition which certain writers — who,
upon a priori grounds rather than on the results of clinical
experience, group sciatica and tic in the same category —
have lately enforced with some emphasis, and which
therefore merits the attention of those who may in future
study sciatica. For myself, I must say that the records of
thirty cases lead me to believe that there is nothing to
support the idea that sciatica is inherited ; indeed, quite
the contrary. To be sure, if we were to include sciatica
among the common neuralgias, and we were to ask each
patient whether his father or mother had suffered face-
ache, we should get an answer in nearly every case in
the affirmative. Who has had a father or mother who
has not had faceache (or toothache) ? But, I would ask.
2 2 SCIATICA: A FRESH STUDY
is this a legitimate method of accumulating medical
statistics ? Is it not such statistics as these that give rise
to the assertion that ' there is nothing so false as facts
except figures ' ? Inheritance, then, in sciatica I hold to
be no condition whatever.
" Another somewhat unsatisfactory condition of sciatica
is that which is sometimes given — that of unilaterality.
To say that a disease is unilateral is simply to predicate
that which may be said of nearly all our ailments. It is
only a small proportion of human ills which are bilateral,
and it happens unfortunately for the supposed character
of sciatica that sciatica is in some few instances present in
both limbs. It may be stated that the right leg is
oftener affected than the left ; we may dismiss this also as
without useful significance.
" The state of the alimentary canal appears to me to
supply us with a condition which has some constancy.
I find in the great bulk of my cases that the function of
the digestive tract is much impaired. This disturbance
would not be surprising in advanced cases of the disease,
for in all such the pain, sleeplessness and anxiety gravely
interfere with digestion. But I think it is worthy of
note that, in a very considerable number of cases, if the
patient declares that for some time previous to the
commencement of pain in the thigh he has suffered from
'dyspepsia,' further inquiry will show that constipation,
pyrosis, and even haemorrhoids, have had their way for a
long while. The presence of piles in cases of sciatica
has been often pointed out, and the fact is worthy of
more consideration than it has received. The vascular
relations of the sciatic and the rectum may, I doubt not,
have important influence on certain cases of sciatica,
HISTORICAL 23
though the exact pathological nature of this influence
remains to be worked out.
" Concerning conditions of diet, there is nothing to be
said that can have any scientific weight.
" Finally, as to the condition of the nerve itself, as I
have said in an earlier page, we are not justified, as
seekers after truth, in jumping to the pathological con-
clusion which is, I regret to think, so dogmatically laid
down in some of our treatises. Sciatica is a disease of no
rarity, yet only one or two cases have occurred in which
the nerve has been examined. From the results of
observation in these, it is concluded that in all sciatic
cases the nerve sheath is inflamed, swollen, and filled
with a gelatinous fluid. But is this fair ? It is less
absurd than the generalization of that proverbial French-
man, who, finding the barmaid of an English hotel red-
haired, immediately wrote down, ' English women have
red hair.' The matter is really a serious one, for not
only is it damaging to the character of medicine as
a science, but it is attended with grave results to
medicine as an art. For what do we find ? Why, that
one physician, unquestioningly accepting this mere
hypothesis, treats his cases of sciatica with iodide of
potassium to absorb the gelatinous liquid of the nerve
sheath, and thus to prevent the lameness which follows
pressure on the filaments ; and another, who, for the
same reason, tells us that he cures his cases by puncturing
the sheath with a large needle, and thus allowing the
* gelatinous fluid ' to escape. We cannot question the
workings of the iodide, but I should certainly like to
know that physician who knows when he has reached
and perforated the sciatic nerve. It is, certes, a delicate
24 SCIATICA : A FRESH STUDY
little bit of operating. In conclusion, and en parenthese^
I must express my opinion that the lameness in sciatica
is not caused by pressure of the sheath benumbing the
nervous filaments, as contended by a distinguished
physician. I have no doubt in my mind that the lame-
ness is not the consequence of want of nervous power,
but of disinclination on the part of the patient to move a
muscle whose motion is extremely painful, and with this
belief I fail entirely to see the rationale of the adminis-
tration of iodide of potassium. It is, perhaps, unwise to
offer any speculation as to the part of the nerve primarily
attacked ; but, if I may be permitted to say so, I have
a strong suspicion that changes of nerve structure com-
mence in those delicate filaments which form such
exquisite reticulations on the surface of the sarcolemma
of the muscle."
Dr. Lawson, himself a victim of severe sciatica,
makes the strong statement that " the history of
the complaint is the record of pathological igno-
rance," and that sciatica " is often confounded with
other maladies."
" Being connected with a supposed degenerate
condition of the nerve trunks, it has, with question-
able justice, been grouped with that vague class of
diseases, neuralgia." He goes on to say that " the
starting-point of the pain is mostly at the upper
portion of the sciatic," and disputes the statement
that the pain is worse at night.
He asserts that flexion of the leg is apt to
HISTORICAL 25
become chronic, and that forcible extension would
lead to serious rupture of the tissues. Tenderness
on pressure over the nerve itself is mostly declared
at its upper third, and "will lie along a line of
from 2 to 4 inches. Spinal tenderness has not
been found to be present.'
Wasting of the limb, he says, is only found in
protracted cases, and this atrophy is due entirely
to disease of the leg, and is not dependent on the
state of the nerve.
He has seen ^^ very great flattening of the
buttock on the affected side,^^ " When the patient
is made to lie on his belly, the difference will then
be apparent almost at a glance,'' He thinks there
is a diminution of sensibility in the affected side,
and that this is due to faults in the circulation of
the blood.
He goes on to say that improper food is a
frequent cause of the complaint. He is very
strong in maintaining that the mere fact of the
nerve being examined in one or two examples of
a not uncommon disease falls very short of proving
that it is the rule that " the sheath is inflamed and
filled with a gelatinous fluid." " He would like
to know that physician who knows when he has
reached and perforated the sciatic nerve."
I would beg to draw special attention to what
he says of wasting of the buttock on the affected
2 6 SCIATICA : A FRESH STUDY
side as an important confirmation of my own
experience, as shown in the illustrations ; also that
the pain starts in the upper third of the nerve.
He is wrong, in my opinion, in asserting that
atrophy of the local muscles is not a striking
characteristic of sciatica. To my mind, it shows
the intimate connection between the nerves of the
hip-joint and those that supply these muscles.
Many years ago I had noticed this atrophy
in affections of the joint and in fractures in the
lower animals. The constant tonic contraction
from irritation prevents rest on the part of the
muscles, and thus interferes with their proper
nourishment.
A study of Dr. Eccles' able book* does not help
us to any further knowledge of the pathology of
sciatica. He is an implicit follower of Gowers.
Neither is anything new to be found in Harburdf
nor in Harris's paper,| nor indeed in Fowler's. § All
these authors stick to the same well-beaten track
of "neuritis," "perineuritis," and so on. Dr.
B. Bosanyell gets out of the difficulty by limiting
sciatica proper to cases where there is no hip
^ "Sciatica," 1893.
t Medical Press^ September 28, 1904.
I Clinical Journal^ ]?in\x2Lry 13, 1909.
§ Practitioner^ 1904? vol. Ixxviii., p. 410.
II Lancet^ November 24, 1906, p. 1472.
HISTORICAL 27
trouble, which he allows is a restricted class. Dr.
Verebely refers to swelling of the nerve sheath,
and notes the presence of uric acid in the effusion,
as also of fat ! But the result is scarcely worth
referring to, being an example of the sloppiness
too common with writers on sciatica. Adam,^
in his "Pathology," attempts to take a philo-
sophical view of sciatica ; but, I fear, however
plausible his explanations when he tries to
account for the pain, he fails to leave us with
any clear idea of what, after all, one wants to
know : What starts the pain? It is inconceivable,
if it be really central, that it should come and go
as it does, and why there should not be in
ordinary cases some distinct physical evidence of
local disease in the cord.
Mr. Bowlby,f in a very interesting lecture on
pain, refers to sciatica in the following terms :
'' There is one diagnosis due to referred pain, of
which I am even more suspicious than I am of
rheumatism — viz., sciatica. What numberless
diseases have been lumped together under that
misleading title ! and how extraordinary it is to
see over and over again that so long as a pain can
be given a name that is commonly recognized, the
patient seems to be perfectly satisfied !" And he
* "Pathology," 1909.
t Clinical Journal^ February 24, 1 904.
28 SCIATICA : A FRESH STUDY
goes on to quote a series of cases where the real
seat of the pain was not in the sciatic nerve, but
outside the nerve altogether.
Wilson, in his '' Handbook of Medical Diag-
nosis,"* after describing the anatomical arrange-
ments of the sciatic nerve, gives the accepted view
of the pathology which has been already re-
ferred to.
Dr. Shoemaker of Philadelphia, in a lecture on
sciatica,! quotes the case of a man of fifty-five
years of age, and deals with its pathology, etiology,
and treatment in the orthodox manner. J "Gold-
thwait's disease," as it has been called, opens up
a new line of inquiry in connection with sciatica.
In so far as the symptoms of the complaint in
stout, obese women is due to relaxation of the
pelvic ligaments, it may be allowed to be present
as a rare affection, and one necessary to be kept
in mind in examining cases of sciatica.
Three years ago Dr. Welford Harris read a
paper before the Medical Society of London on
the diagnosis and treatment of sciatica, in which
he discussed, in the accepted style, the disease as
neuritis of kinds, taking his pathology for granted.
* 1909.
t Monthly Cyclopcedia and Medical Bulletin^ Phila-
delphia, July, 1909,
X Hospital^ December 11, 1909.
HISTORICAL 29
He proceeded on this assumption to classify the
complaint as acute and chronic. Once started
with a good-going hypothesis, explanation is easy,
and the treatment of symptoms can be readily
adapted to correspond.
He makes little reference to the physical con-
dition of the affected limb, and I doubt very much
if he troubled to make any systematic examination
of the part affected. His praises as to the advan-
tage of the use of an air or water bed are much to
be commended. The after-discussion elicited no
fresh points, and need not be referred to.
Brindley James's plan of treatment belongs
mainly to the usual category.
Coming to still later writers of authority,
Aldren Turner, and Grainger Stewart's " Hand-
book of Nervous Diseases,"* may be shortly
referred to. They allow that the pain of sciatica
is a common accompaniment of osteo-arthritis of
the hip-joint, as (they say very truly) brachial
neuralgia is frequently associated with a similar
affection of the shoulder-joint. They adopt the
accepted opinions as to the pathology and etiology
of the disease, and likewise of its diagnosis. They
speak of altered electric excitability of the muscles,
and refer without particulars to the use of the
Rontgen rays as bearing on the latter question.
* 1910.
30 SCIATICA : A FRESH STUDY
They make a pregnant remark where they say they
have seen "sudden turning in bed bring on a
relapse more severe than the original affection."
Then they go on to recommend the best forms of
treatment.
Dr. Alfred Gordon* of Philadelphia, in a very
able paper published lately, proceeds to analyze
the causes of pain in sciatica, and quotes two cases,
differentiating between what he calls " classical "
sciatica and " radicular '' sciatica. In the latter
variety, he says, the distribution of a sensory root
in the skin does not at all correspond to the mode
of distribution of a peripheral nerve trunk ; a
lesion within the canal, such as tumour, pachy-
meningitis, or disease of the bone, may affect only
one of the roots of the nerve trunk. Should the
sensory root alone be involved, the sensory dis-
turbance will follow a special root or radicular
disturbance. Holding these distinctions in mind,
he goes on to say they led him to look for the
morbid process " not in the sciatic nerve, but
higher up towards the sacral plexus." A careful
examination of one of these cases led to the
discovery of a slight but undoubted enlargement
of the sacrum on the affected side, "which evi-
dently compressed and irritated the sensory
■^ " Diseases of Nervous System," 1908.
HISTORICAL 31
branches of the posterior division over the integu-
ment of the gluteal region of the sacrum."
I have given Dr. Gordon's views at length,
because if they were applicable generally, my main
contention as developed at length farther on would
fail to be proven. But he must be alluding to
a very special, and, I hold, an exceedingly rare,
form of sciatica. Referred pains must still be
taken as the fair and proper indication both of the
precise route and the real origin, through their
proper centres, of the pains to be investigated.
Up to this point I have tried, I hope success-
fully, to give a fair account of sciatica as described
in the ordinary textbooks of the practice of
medicine, and dealt with in special treatises. I
come now to closer quarters with my subject, and
proceed to state, as succinctly as I can, the views
I hold, and to give the facts and arguments which,
in my humble opinion, bear out my contention as
to the correct pathology of the disease being
essentially Trouble in the hip-joint.
CHAPTER II
MY OWN THEORY
Sciatica is a comprehensive term^ and one
familiar — perhaps too familiar — both to the
patient and to his physician. So much is this the
case that I fear many medical men are content
with the subjective evidence, and neglect the
objective aspects of the disease. Indeed, I can
only thus explain the present persistent ignorance,
if I may be allowed to use such a phrase, as to its
real nature, which seems universally to prevail.
It is one of many examples of the dangers of
generalizing too much, and of the mistaken idea
that if we are able to label a complaint with an
appropriate name, we, as a matter of course, know
how to cure it. No belief could be more fatal to
sound practice, not only in this case, but — I
may be pardoned for saying — in that of almost
every ailment which affects humanity. In my
early days I was content to accept what was the
general rule, the patient's or his medical adviser's
diagnosis, and without any special local examina-
32
MY OWN THEORY 33
tion of the affected limb to proceed to treat sciatica
by the usual round of waters, baths, and massage.
The first clear indication for treatment I came
to see as being imperative was the necessity for
rest, and the bad effects resulting from insisting
on or allowing exercise or very rough or excessive
massage of the limb. I was struck with this
peculiarity in a disease which was supposed to
depend to a large extent on mental conditions,
and which distraction of any kind should usually
alleviate. Having thus become convinced of the
absolute need for rest, I began to consider whether
sciatica might not he an affection of the hip -joint.
About this time I came across some remarks of a
great surgeon, unfortunately no longer with us and
science, Sir Jonathan Hutchinson, who was of the
opinion that a certain number of cases of sciatica
were really due to " trouble in the joint." The
next step in the history of the evolution of my
opinions was naturally the careful examination of
the limbs of patients affected with sciatica.
Following out these views, my mind reverted
to a book which had impressed me in my early
days more than any other treatise in the whole
range of surgical literature — viz., Hilton on " Rest
and Pain." I made a careful study of his writings,
and became still more convinced that sciatica had
its real origin in trouble within the hip-joint. I
3
34 SCIATICA : A FRESH STUDY
cannot do better than quote his weighty remarks.
They may not always directly bear upon the
subject, yet in spirit they are particularly apposite
to my argument, and I trust I may be excused for
giving them at some length :
" Pain in any part, when not associated
with increase of temperature (the local symp-
tom of local inflammation), must be looked
upon as sympathetic pain caused by an
exalted sensitiveness of the nerves of that
part, and it is to be regarded as a pain de-
pending upon a cause situated remotely from
the place where it is felt. In availing our-
selves of these so-called sympathetic pains
(and no doubt they are in a sense sympa-
thetic pains), I should like to displace, to
throw aside, the term ' sympathetic ' as some-
thing too ideal, and would ask you to con-
sider such pains in their obvious, intelligible^
and more natural relation. I would ask you
to regard them as resulting from some direct
nervous communication passing between the
part where the pains are expressed, and the
real and remotely situated cause of the pain.
" Now, external pain, or pain upon the
surface of the body, if properly appreciated,
may be considered as an external sign of
MY OWN THEORY 2s
some distant derangement. If the pain per-
sists — when it does not depend on any
transient cause — it becomes necessary to seek
the precise position of the pain ; and, as soon
as we recognize the precise position of the
pain, we are enabled, by a knowledge of
the distribution of the nerve or nerves of
that part, to arrive at once at the only
rational suggestion as to what nerve is the
exponent of the symptom. By following
centripetally the course of that nerve, and
bearing in mind its relation to surrounding
structures, we shall, in all probability —
indeed, most likely — be able to reach the
original, the producing, cause of pain, and
consequently to adopt the correct diagnosis.
" In order to bring in a comprehensive
and definite form before you this fact, which
is so important on anatomical, physiological,
and pathological grounds, I will state it thus :
"The same trunks of nerves, whose
branches supply the groups of muscles
moving a joint, furnish also a distribution
of nerves to the skin over the insertions of
the same muscles ; and, what at this
moment more especially merits our atten-
tion, the interior of the joint receives its
nerves from the same source.
36 SCIATICA : A FRESH STUDY
"This implies an accurate and consent-
aneous physiological harmony in these various
co-operating structures.
" I shall be able hereafter to trace nerves
derived from the same trunk supplying the
joint and muscle.
" The object of such a distribution of
nerves to the muscular and articular struc-
tures of a joint in accurate association is to
insure mechanical physiological consent be-
tween the external muscular or moving force
and the vital endurance of the parts moved
' — namely, of the joints — thus securing in
health the true balance of force and friction
until deterioration occurs. If this point of
balance or adjustment be over-reached during
exertion, pain — Nature's warning prompter —
is induced within the joint, and suggests the
necessity of diminishing or arresting exertion.
This cessation, or this reduction of exercise,
or friction, and pressure upon the articular
structures, must be effected by the muscular
apparatus of the joint, either through the
will, or immediately by its own instinctive
efforts, called into play by means of the
nervous association. The muscles appear to
be told, through the medium of the nerves of
the interior of the joint, that its articular
MY OWN THEORY 37
structures are overtasked ; and the antagon-
istic muscular forces of the joint being thus
involuntarily excited, the joint is at once
rendered rigid and stiff, for the purpose of
keeping it at rest.
" Without this nervous association in the
muscular and articular structures, there would
be no intimation by the internal parts of
their exhausted function. There cannot be
any doubt that it is when this period of
functional exhaustion in the internal parts
has been reached, and articular friction is
nevertheless continued (notwithstanding the
structural and functional prostration), that
the mischief to the articular structures com-
mences, and disease of the joints, as we term
it, starts into existence.
" Again, through the medium of this
muscular and cutaneous nervous association,
great security is given to the joint itself by
those muscles being made aware of the point
of contact by any extraneous force or violence.
Their involuntary contraction instinctively
makes the surrounding structures tense and
rigid, and thus brings about an improved
defence for the subjacent joint structures.
" This articular, muscular, and cutaneous,
or peripheral, distribution of the nerves is, in
38 SCIATICA: A FRESH STUDY
my opinion, a uniform arrangement in every
joint of the body.
" When the interior of the joint is in a
state of inflammation or of irritation, the
influence of this condition is carried to the
spinal marrow, and thence reflected to the
various muscles of the joint through the
medium of the associated motor nerves, the
muscles being supplied by the same nerves
that supply the interior of the joint.
** The joints of the human body which
are the least likely to sufi^er from internal
injury, or from over-exercise or fatigue, are
also the most free from disease. This indi-
cates a probable relation between their free-
dom from external injury, or from over-work,
and their immunity from disease."
He goes on to say :
" I shall not dwell upon the anatomy of
the hip-joint, except to remind you that its
muscles perform their functions in groups,
that each group has a trunk nerve of its own,
and that each nerve contributes a branch to
the hip-joint itself. A branch of the anterior
crural nerve passes to the hip-joint, a branch
of the obturator going to the capsular ligament
and to the ligamentum teres, and a branch
MY OWN THEORY 39
proceeding to the posterior aspect of the hip-
joint from the sacral plexus, which supplies
the gemelli, the quadratus femoris, and the
obturator internus. This anatomy should
be borne in mind, because it explains how it
happens that the remote and sympathetic
pains associated with an inflammatory con-
dition or chronic disease of the hip-joint are
not always found at the same part of the
limb. We all know that in some cases of
hip-joint disease one of the earliest symptoms
is remote from the actual seat of mischief —
namely, pain within the knee or on the inner
side of the knee-joint ; and we are familiar
with the explanation of it — namely, that the
obturator nerve, which contributes a branch
to the ligamentum teres, sends a branch to
the interior of the knee-joint, to the inner
side of it, and sometimes even lower down.
The inflammation or a diseased condition of
this ligament necessarily involves the little
branch of the obturator nerve, and a sympa-
thetic pain is produced at the other end of the
same nerve, on the other side of the knee or
within the knee-joint. As it is frequently
with the obturator, so it ought to be some-
times with respect to the other nerves of the
hip-joint ; but the frequency of this knee
40 SCIATICA : A FRESH STUDY
pain, whether within the knee-joint or on its
inner side, indicates that the ligamentum
teres is the most common seat of early disease."
And again :
"Now, suppose the anterior part of the cap-
sular ligament (which receives a branch from
the anterior crural) is inflamed. Applying
the same law you will see how it may happen
that a patient with a diseased hip-joint may
have pain on the front of the knee or on the
inner side of the ankle, because the anterior
crural nerve sends branches to these particular
spots. Or if the inflammation or injury begins
at the posterior part of the capsular ligament,
which receives a branch or branches from the
sacral plexus, then the patient may have a
sympathetic pain actually at the heel or in the
foot, I repeat these remarks in reference to
the nervous supply, because an impression,
I think, is abroad that the sympathetic pain
of hip-joint disease is always on the inner
side of the knee-joint, and that this local
symptom is essential to a correct diagnosis.
This, it seems to me, is not true. I admit
its greater frequency, because, as has been
already intimated, the ligamentum teres is,
perhaps, the part where hip-joint disease in
MY OWN THEORY 41
reality most commonly begins, and this
corresponds with the frequent observation of
the ' sympathetic ' pain on the inner side of, or
within, the knee. To put this point more
strongly, it sometimes happens in hip-joint
disease that there is no pain in the knee-joint
at all. (I have seen several such cases.) This
local pain, therefore, must be considered as
a fortuitous, not a constant, symptom, and
not always to be relied upon as indicative of
diseased hip-joint."
So much for Mr. Hilton.
In patients the subjects of sciatica, wasting of
the muscles of the hip in nearly all cases of the
complaint is very decided. Indeed, this atrophy
is often as plain as it usually is in tuberculous
morbus coxae, and so, fortified by Hilton, I be-
came still more convinced that the associated set
of symptoms known as *' sciatica " were the result
of reflex irritation originating from troubles in
the hip-joint.
Another proof of hip trouble also very fre-
quently present was marked tenderness on pres-
sure over the capsule of the joint, more especially
at its upper and back part.
Altogether, I felt justified in a systematic at-
tempt, by close examination of the articulation,
42 SCIATICA : A FRESH STUDY
to find out whether my surmises would hold
water. So with this view, / proceeded to examine
every patient I came across and to keep notes,
which I have printed in an appendix. These are
an exact transcript of what I wrote down at the
moment 1 made the examination.
The next step in my investigations was to find
out the effect of passive movements in the articula-
tion. For this purpose I carefully scrutinized, and
recorded the results, by a deliberate process of local
examination, as I shall now proceed to explain.
In examining a patient the subject of sciatica,
there is a certain routine which I have found
from a lengthened experience to be best, and I
would venture to recommend my professional
brethren to follow the same method. Ask the
patient to lie down, fully dressed, on his back on
an even, firm couch ; then bending the affected
limb at the knee, perform the passive movements
of flexion, external rotation, internal rotation, and
extension, by Thomas's method, at the hip-joint
of the affected leg. If the case be at all recent,
one or more of these movements will cause pain,
very often sharp pain, as the patient's countenance
frequently reveals. Having carefully noted these
signs, then ask him to undress, and proceed to
inspect the gluteal region. With the patient
lying flat on his face and relaxing his muscles.
MY OWN THEORY 43
you note whether there is wasting in this region,
or a diminution in the original number of the
folds of the nates ; and on comparing those of the
opposite hip, and the two thighs also together, I
venture to confidently predict that in almost every
case of sciatica you will discover softening, or
wasting and flattening, of the hip muscles, and
more or less obliteration of the natal folds of the
affected side. With the patient lying on his
sound side, you then proceed to inspect the
capsule of the hip-joint. In some cases you will
find it more prominent on the aff'ected side, and
in a very few (but very seldom, for obvious
reasons) you may be able to discover that there
is increased heat over the joint. The position
of the articulation is best made out by making
sure of the exact relation of the anterior superior
iliac spine and the highest point of the trochanter
corresponding to the joint you suppose to be
affected. The next thing to do is to examine
carefully and without prejudice the presence or
absence of tenderness on pressure over the capsule.
This investigation has to be gone about keeping
in view the fact that the patient is not an impartial
witness, so to speak. He is very apt to confound
symptoms with signs, and his mind has been so
intent on the suffering, say, in his foot, that he
refuses to help you in your attempts to discover
44 SCIATICA : A FRESH STUDY
the important sign you wish to make out — Le.^
whether coxal tenderness be present or absent.
When it is considerable, you are independent of
his preconceived ideas. In many cases moderate
pressure with the point of the thumb over some
parts of the capsule causes so much pain that he
winces unmistakably. Of course, to make your-
self certain, you compare the two sides, and by all
means follow the line of the sciatic nerve, and try
to discover whether there is, or is not, tenderness
on pressure along its course.
On the hypothesis, then, that the true cause of
sciatica is trouble in the hip-joint of the leg
affected, and that the pains complained of are
referred or reflected pains, the following descrip-
tion of the nerves involved, as given me by Dr.
Calder, will show by what routes the irritation,
starting in the diseased articulation, may travel.
Possible Paths of Referred Pain in
Sciatica.
I. The pain may be referred from the hip-joint
along the articular branch of the nerve to
the quadratus femoris, which comes from
the fourth and fifth lumbar and first sacral
spinal cord segments, back to the cord,
and thence along the musculo-cutaneous
branch of the external popliteal nerve.
MY OWN THEORY 45
which comes from the fourth and fifth
lumbar and first and second sacral spinal
segments, to the peroneal region of the leg.
2. It may be referred from the hip-joint along
the articular filaments of the great sciatic
nerve, which come from the fourth and
fifth lumbar and first sacral spinal cord
segments, along the branch of the posterior
tibial nerve, which comes from the first and
second sacral spinal cord segments.
By the great kindness of Professor Reid I am
able to quote his weighty statement of the
anatomical details of the nervous arrangements of
the hip-joint. He says :
'' Suppose the disease [sciatica] is an
affection of the hip-joint, associated with
rheumatic deposit in the region of the upper
and hinder part of the acetabular border, I
can quite conceive that the pain in such a
case may be a referred pain brought about
thus. An articular branch of the hip-joint
leaves the fourth and fifth lumbar and the
first sacral spinal cord segments. On its
passage to enter the back of the joint it lies
close to the hind border of the acetabulum,
and might easily get involved in mischief
there. From the fifth lumbar and first and
46 SCIATICA : A FRESH STUDY
second sacral cord segments, cutaneous
nerves are divided for distribution in the
skin over the peroneal region of the leg.
Might not the pain be referred from the
articular nerve to those cutaneous fila-
ments ? Again, as to the pain in sciatica
felt on the skin over the back and inside of
the heelj this area has sensation supplied by
the calcaneo-plantar nerves, offsets of the
posterior-tibial nerves, but ultimately derived
from the first and second spinal cord seg-
ments. Might not this pain also be referred
from the articular branch mentioned above
to those cutaneous twigs ?"
The series of tables which follow give the
result of my observations on certain specified
points. As to other particulars, I am sorry I
cannot bring forward evidence on the question of
employment or profession ; but even if I did,
the figures would hardly afford a fair criterion, as
naturally only those who could afford to visit a
health resort like Strathpeffer would be included,
while the poorest class of sufferers (perhaps the
most commonly attacked) would be left out.
Neither have I evidence to offer as to which leg
is the more liable to be attacked, nor, which is
really a highly important fact if noted, the
presence or absence of lameness of the affected
MY OWN THEORY
47
limb. But in the latter respect inability to make
perfect use of the leg may be taken for granted.
Lameness is a symptom which is universally
allowed to be almost invariably present.
Table I. gives the broad result of 676 cases
of sciatica. All came under my direct cognizance,
and most of them under my own care and
treatment, in the course of twenty-three years'
practice. The numbers may appear large, but
Gibson has a record of 120 cases seen in Buxton
Hospital during a single year.
TABLE L
Ages.
Males.
Females.
Total.
20-29
30-39
40-49
50-59
60-69
70-79
17
, 34
58
100
III
40
13
30
62
91
62
28
30 j
64 1
120 i
191
'11
—
360
286
646 i
1
]
29 cases
675
Ages and sex not recorded
Grand total
It may be remarked that more than half the
special cases, and 48 per cent, of 293 not
specially noted, showed signs of rheumatism or
gout. My impression is that the majority of
these were examples of gout ; and so that fact, if
48
SCIATICA : A FRESH STUDY
established, points to the conclusion that sciatica
is a trouble connected with a particular joint,
seeing that gout so frequently affects joints in
that way, apparently for the reason that the
circulation in these parts of the body is so readily
disordered as the result of repeated shocks. The
buffer, the interarticular cartilage, proving in-
sufficient to protect the vessels supplying the joint
from pressure, the result is slowing of the blood-
circulation and a tendency towards deposit of uric
acid salts. I take it as undoubted that there is in
gout an excess of uric acid in the system, whether
from over-formation or from defects in the elimina-
tion of this product of metabolism.
TABLE II.
Diagnostic Results obtained from 125 Specially
Observed Cases.
— .
Result of Observations.
Cases.
Per Cent.
Gout or rheumatism ...
65
52
Lumbago
28
22
Pain on flexion
49
39
Pain on external rotation
48
38
Pain on internal rotation
51
41
Wasting of glutei
49
39
Incomplete natal folds
37
30
Tenderness over capsule
69
55
One or other of these signs was observed in 100 cases,
or 80 per cent.
MY OWN THEORY
49
In 39 per cent. (Table II.) there was pain on
flexion, in 41 per cent, pain on rotation inwards,
and in 38 per cent, on rotation outwards. In only
a very limited number was there found manifest
distension of the capsule, say, i per cent. ; and in
a still smaller number — 0*25 per cent. — was there
any evidence of heat discovered over the joint.
In 52 per cent, of the cases there was evidence of
gout or rheumatism in other joints, and in 22 per
cent, there was evidence of the occurrence of
lumbago. In 80 per cent, of the cases taken
altogether one or other of the above symptoms
was present. A small number of cases which
had begun as sciatica had gone on to ankylosis
of the joint, and would have been set down as
examples of rheumatoid arthritis of the hip.
The ratio shown of males to females is about
4 to 3. The preponderance of males is not nearly
so much as I find stated by other observers. For
instance, in 124 cases reported by Valleix, the
proportion of males is 72 to 52, while Fuller
gives as many as 61 to 14. As regards age
incidence, I find that the greatest number of cases
occur between fifty and fifty-nine years of age,
followed closely by those from sixty to sixty-nine
years, though no age except the very earliest is
exempt from the possibility of attack. With
regard to position in life, my own impression is
so SCIATIgA^ A FRESe-m;UDY
that it is as frejjueiatlillidnlgsflilSe pj^ as amongst
the rich. It would not give fair resuj^ to quote my
own statistics oirfcfei^^^gAff&is'^inion would be
decidedly confirmed if we include cases of rheuma-
toid arthritis of the hip-joint, sciatica-^' being, I
believe, merely a preliminary stage of this crippling
disease, and one from which the poor, from plain
reasons, are likely to be greater sufferers than the
rich.
In studying the natural history of sciatica, I was
much struck, early in my investigations, by its
frequent association with "lumbago.*' This coin-
cidence will be apparent to the reader who takes
the trouble to examine the cases detailed in
Appendix II.
What is the explanation of this coincidence ? I
believe the reason to be this: When trouble begins in
the hip-joint the tendency on the part of the patient
is to throw the weight of the body off the joint,
so as to relieve the pressure in the affected articula-
tion. In this way we get a partial scoliosis, but at
the expense of the lumbar muscles, which suffer
from the constant strain, and show that they do so
by inducing the well-known symptoms of lumbago.
And here I may also call attention to the reason
why the position of greatest tenderness on pres-
sure over the joint is almost always situated at
the upper edge of the acetabulum. It is so
MY OWN THEORY 51
because this is the region where the shock of the
weight of the body, when thrown on the hip-joint,
falls most strongly, and where also, on long-
continued standing, undue pressure is most con-
tinuously exerted. We see instances of the former
class in the frequent occurrence of sciatica amongst
carters and cabmen, and of the latter in the case of
architects and artists. Doubtless, also, sciatica in
women is often due to the fact that busy matrons
have to be for hours almost continuously on their
feet.
So much for each of the signs I have brought
forward in proof of my contention that the cause
of sciatica is trouble in the hip-joint. The reasons
are strong individually, but, surely, when taken
collectively they are still more cogent. On the
assumption that the pain and other symptoms are
the result of neuritis, I hold there is a want of
physical evidence. There is scarcely any plain
proof. At best, though generally accepted, it
amounts to very little more than a plausible hypo-
thesis. On the contrary, the fact that in sciatica
there is found, as the rule, a set of well-established
signs of disease in the hip-joint sufficient to
account for the symptoms, is enough, in my
humble opinion, to decide the question in favour
of this latter contention as against the former. It
may be said, " Yes, you have shown that many
52 SCIATICA : A FRESH STUDY
cases of sciatica are due to diseases in the hip-joint.
But are you justified in affirming that all cases of
sciatica are due to this cause ?" I believe when it
is found that so large a proportion of cases is due
to hip-joint trouble, it is philosophical to assume
that the remaining cases also belong to the same
category. Other explanations are insufficient, and,
as I have said, hypothetical. It would be too
much to expect that every diseased hip-joint in
its early stages would show manifest signs under
examination so that one could affirm the
positive presence or absence of such mischief.
Before, however, going on to mention ordinary
typical cases, I may be allowed to give a note
of what I consider an instructive instance of
so-called sciatica. The patient had been ailing for
four years, the disease beginning with pain in his
back, shooting down his thighs. He consulted a
bath physician, took waters, and was systematically
douched, with improvement. By-and-by he saw
another spa doctor, who cursorily examined him
and prescribed some medicine ; and so matters
went on until he came to me. I had him stripped
and properly examined, when I found he could
flex his right thigh on the abdomen only to the
extent of 90°, rotation was entirely gone, the
natal folds were much obliterated, and the glutei
wasted, with some wasting also of the muscles of
MY OWN THEORY 53
his thigh. There was still present sHght but
sufficiently well-marked tenderness on pressure
over the capsule of the hip-joint on that side. As
regards the left leg, the buttock was much firmer,
there was a limited amount of circumduction,
flexion being fairly full. Tenderness on pressure
over the hip-joint could be easily elicited. Now,
here was a man practically lamed for life. I do
not hesitate to affirm, from a large experience
of such cases, that this double arthritis of the hip-
joint, and consequent ankylosis, with a steady
course of massage and regulated passive move-
ments, might, if not cured, at least have been
greatly stayed in its terrible progress. Why were
not these proper means used to secure a happy
result ? Not, certainly, because the two previous
doctors were not as fully competent as myself, per-
haps they were more competent, but simply because
they had not taken the trouble to examine the
patient systematically and thoroughly, misled by
an erroneous pathology, and leaning on words,
mere words ; trusting to books and not to their
own brains to keep them right.
But v/hile here the history is plain enough, 1
think I am entitled to enter a " caveat " that it
would be too much, as I have said, to expect that
every diseased hip-joint in its early stages should
show manifest signs under the various heads pre-
54 SCIATICA : A FRESH STUDY
viously mentioned. Sciatica — and this remark, as
I have said, applies to other rheumatic joints, such
as the knee and shoulder — is apt to come and
go after an erratic fashion ; probably this coming
and going depending on the varying amount of
effusion in the joint.
Another point in favour of my contention is the
good eff'ect of rest, on the one hand, and well-
directed massage on the other. These are allowed
to be infallible indications for the proper treatment
of inflamed joints, according to Mr. Hilton. Sir
James Paget, at a later date, strongly advocated
the same principle. Certainly they ought to be
guides in dealing with sciatica, and so far they
favour the view that the complaint is arthritic.
So accomplished a physician as Osier advocates
very strongly the need for rest to the affected
limb, and even goes the length of insisting, in very
severe cases, upon the application of the long splint
to the affected leg. One wonders how he did not
take one step more and come to see that such a
support fixes the hip-joint, and by so doing re-
lieves the pain, giving the articulation (just as in
so-called strumous disease) the best chance for
recovery.
We have seen that there is no proof of any
real neuritis of the sciatic nerve ; that there are
ample means of communication between the ex-
MY OWN THEORY SS
tremities of the nerves in the joint and the surface
of the skin of the Itg ; that movements of the
joint are often either limited in extent or cause
pain, or both ; that the muscles most closely con-
nected with the hip articulation become atrophied ;
that there is very often tenderness on pressure
over the capsule of the hip-joint, and even some
swelling, and occasionally — but rarely for a
manifest reason — a feeling of heat imparted to
the surgeon's hand ; that sciatica is universally
admitted to be related to gout or rheumatism
in most patients ; and, lastly, that gout and
rheumatism are actually simultaneously present in
other articulations.
Most important of all is the fact that in almost
every case of sciatica there is lameness of the limb
affected. The patient constantly limps when
walking. It is true that in a minute percentage of
those I have recorded the sufferer has felt better
when taking exercise. This can easily be explained
on the same principle as that on which properly
applied massage gives relief. Does not the surgeon
in every other case of lameness of the lower
extremities — and, indeed, in every affection of the
movements of the upper limb — proceed primarily
to consider which of the joint surfaces are diseased?
If, on careful examination, there is found no clear
evidence of any trouble anywhere but in the hip
S6 SCIATICA : A FRESH STUDY
joint, while there is such to be found in that
articulation, are we not justified in assuming the
cause of the lameness to be connected with this
joint, and in considering that sciatica means trouble
in the hip-joint, and, as a rule, nowhere else ?
Seeing, then, that trouble of a gouty or rheu-
matic kind in the hip-joint does account for all the
signs and symptoms of sciatica, is there any
necessity to look for other explanations of the
pains ? We have seen that there is no patho-
logical evidence of the presence of neuritis.
Neuralgia is too vague a term to found a decision
upon. By way of illustrating my contention, may
I add that in the course of my studies of the
disease I have come across the following cases
given by Fuller forty years ago (six in all) in his
well-known treatise on " Rheumatism,'* where,
I think, he unconsciously proves that the view of
sciatica as originating in the hip-joint is the
correct one :
In the first case the patient was "easy when
lying down, but the least attempt at motion
invariably caused actual pain in the hip, thigh, and
leg. The acts of coughing, sneezing, or laughing
were also productive of an attack/' In the second
case " the acts of coughing, sneezing, and the least
attempt at motion in bed brought on a paroxysm
(and so also did pressure, however slight, in the
MY OWN THEORY 57
course of the nerve)." In the third case (sciatica
in both legs) " any attempt at motion gave rise to
involuntary starting of the limb." In the fourth
case " his easy position was lying on his back in
bed with his knee slightly flexed. There was not
any tenderness of the nerve on pressure." In the
fifth case "the pain extended from the left hip
down the ankle, but no specially tender spot could
be discovered in the course of the nerve. The
pain was of a dull, wearing character, but was
much increased by motion and every act of
straining, as in coughing, sneezing, and the like."
In every case the origin of pain in the joint seems
a complete explanation of the symptoms. It is
true that he says in one of the cases tenderness on
pressure over the nerve was present, though in
two cases he says it was absent. That the
extremities of the nerves supplying the skin over
the course of the main nerve should have been
excited, so to speak, in this one instance is surely
not to be wondered at, even if the starting-point
was in the hip-joint.
In further support of my views as to the real
source of the pains in sciatica, I venture to insert
the substance of a paper read by my son, Dr.
Ironside Bruce, before the Medical Society of
London in March, 1905, and published in the
Practitioner in April of the same year :
58 SCIATICA: A FRESH STUDY
"The Relation between Sciatica and
Disease of the Hip-Joint.
" In order to obtain such evidence, with a view
to demonstrating the truth or otherwise of Dr.
Bruce's contention, I have taken from time to
time, as opportunity offered, radiograms of the
hip-joint in cases of sciatica. Briefly I may say
that, in most of the cases offering typical symptoms
of old-standing sciatica, I have found demonstrable
changes in the joint.
" It must be remembered, however, that the
X-ray shadow of the head of the femur and
acetabulum being in profile, a radiogram will only
show changes in the outline if these changes are
present at the upper or lower aspects of the joint.
Changes in the anterior or posterior aspects of the
joint, if not extending to the upper or lower parts,
would therefore not be recognized by this method
of examination. In early cases also, when the
changes are confined to some inflammatory thicken-
ing in the synovial membrane, or to slight deposits
of calcareous material or uric acid salts, the altera-
tion in the structure of the joint might be so
slight that a radiogram would not clearly demon-
strate it. Thus a certain number of cases sub-
mitted to examination (early cases of arthritis, or
those cases in which the alterations in the structure
MY OWN THEORY 59
of the joint are slight) would not offer clear evidence
of an arthritis, which may still, however, be present.
" In order to demonstrate the excellent evidence
of chronic arthritis which may be obtained by the
use of the Rontgen rays, I wish to draw your atten-
tion to a radiogram of the hip-joint of a woman
aged thirty-five. The case is one of arthritis defor-
mans, which had presented difficulties in diagnosis.
"The radiogram (Plate IV., Fig. i) is the
joint on the unaffected side ; and the radiogram
(Plate IV., Fig. 2) is the diseased joint. If the
two figures are compared, an appearance of trans-
lucency is seen in the latter over the head and
upper part of the neck of the femur, which is limited
externally by a sharply defined circular margin.
This appearance is often seen in similar cases ; the
diminution of normal opacity is due to rarefaction
of bone. There is marked lipping of the acetabu-
lum, and the shortening and thickening of the
neck of the femur are well seen. Surrounding
the joint there is a certain amount of opacity,
which may be accounted for by supposing that
there is some infiltration of the capsule and liga-
ments, opaque to the rays.
" Arthritis of gouty origin may often be de-
monstrated by the aid of the X ray.*
* Extra number of the Practitioner on " X Rays in
Diagnosis," Plate XV., Fig. 2.
6o SCIATICA : A FRESH STUDY
" Thus it will be seen that chronic arthritis in a
deep-seated joint, such as the hip, may be demon-
strated in a radiogram, and that gouty as well as
other chronic inflammations may be discovered in
this way.
^^ First Case. — The first case is that of a mian,
aged fifty-six, admitted into Charing Cross Hos-
pital under Dr. Abercrombie. He worked as a
boiler stoker in a large hotel, and came into the
hospital complaining of pain in the left leg, which
prevented him from working, and which he de-
scribed as a burning, shooting pain affecting the
whole limb, but particularly the posterior aspect.
It was sufficient at times to prevent him from
sleeping at night. The pain gradually got worse,
and v/as always worse at night. He could not
turn in bed, and even the weight of the bedclothes
caused him distress. He said that the only way in
which he could get relief from the pain for some
time before he came into hospital was to walk with
a weight in his left hand. The pain was felt on
the surface of the limb over the gluteal region,
down the posterior aspect of the thigh, and along
the posterior and outer aspect of the leg as far as
the ankle-joint. When he was admitted, a diag-
nosis of sciatica was made, and treatment for this
complaint was carried out.
^' On examination the muscles of the gluteal
MY OWN THEORY 6i
region and thigh were found to be wasted, the
patient walked with some eversion of the foot, and
was distinctly lame. Passive movements of the
hip -joint were free, but semiflexion with rotation
inwards and extreme flexion were accompanied by
pain. Pressure over the sciatic notch and in the
popliteal space gave acute pain, as also did deep
pressure over the head of the femur anteriorly.
'' Radiograms of both hip-joints were taken.
The radiogram (Plate V., Fig. i) is the joint
of the sound side. The outline of the bones
forming the joint is clearly defined, and ofl^ers
a great contrast to the condition seen in the
radiogram (Plate V., Fig.. 2) which is the
joint of the aff^ected side. There is the same
appearance of translucency, limited externally by a
circular border, which is seen in the radiogram of
the case of arthritis deformans (Plate IV., Fig. 2).
At the lower part of the outline of the head of the
bone, the normal rounded appearance has been
replaced by opacities with an irregular outline.
Along the upper outline of the joint another
opacity is seen in a position corresponding with
the margin of the acetabulum, indicating new
deposits of bone or other material very opaque to
the rays. The digital fossa, instead of being
clearly outlined is filled up with opaque material.
Ultimately the condition of this patient, owing to
62 SCIATICA : A FRESH STUDY
the continued pain, was such as to justify excision
of the head of the femur. This operation was
carried out by Mr. P. Daniel at the Metropolitan
Hospital, and the portion of bone removed shows
those changes usually associated with arthritis
deformans.
" Second Case. — The second case is that of a man,
aged fifty, living in extremely good circumstances.
He had frequently suffered from attacks of gout
in his shoulder. Suddenly one night he was
attacked with pain in the region of the right hip,
which gradually spread down the whole of the
back of the thigh and leg. He compared the
character of the pain with toothache affecting the
whole limb. While the acute pain lasted, he was
quite unable to move even in bed ; he could not
sleep, and was prostrated by the severity of the
pain. Later, as the acute pain subsided, he was
able to walk, but with some difficulty. Standing
about playing a game like croquet had the effect
of greatly increasing the pain. The pain was
always worse at night. As a rule he could best
obtain relief by sitting down and raising his legs
with his feet higher than his head.
** On examination, there was found slight wasting
of the muscles of the gluteal region and of the
thigh. He walked with a distinct limp, keeping
his knee bent. Pain was observed on pressure
MY OWN THEORY 63
over the sciatic notch and in the popliteal space.
No pain was caused by deep pressure over the
head of the femur anteriorly. The movements of
the joint were free. The pain was felt on the sur-
face of the limb along the posterior and outer
aspects of the thigh, and over the posterior, ex-
ternal, and anterior aspects of the leg, as far as the
ankle-joint. For the purpose of comparing normal
with abnormal, refer to the radiogram (Plate VI.,
Fig. i), which is that of the normal joint;
and Plate VI., Fig. 2, that of the affected joint.
In the latter along the upper outhne of the joint
there is a sharp-pointed excrescence directed up-
wards from the head of the femur, which nearly
reaches the edge of the acetabulum (marked — >).
Opposed to this, from the edge of the acetabulum
arises a slight projection of less opacity than the
bone from which it springs. The apparent trans-
lucency of the outer part of the trochanter is a
photographic phenomenon.
" The Third Case is that of a charwoman, aged
sixty-two, who attended at the Charing Cross
Hospital as an out-patient for electrical treatment
for sciatica. She stated that she suffered at various
times from rheumatic pain in the joints, and lately
had been troubled with increasing pain and lame-
ness of the right leg. These pains had been
gradually increasing in severity for six months ;
64 SCIATICA : A FRESH STUDY
they were always worse after much standing ; they
were worse at night, and often prevented sleep ;
rest relieved the pains. She also stated that the
limb was inclined to give way under her, and that
the skin on the outer side of the leg occasionally
felt numb.
" On examination, the muscles of the gluteal
region and thigh were found to be wasted. Pain
was elicited on pressure over the sciatic notch, in
the popliteal space, and also over the head of the
femur anteriorly. The movements of the joint
were quite free. The position where pain was
felt was stated to be the posterior and outer aspects
of the thigh, and the posterior and outer aspect of
the leg below the knee. In this latter position
the patient experienced the numbness previously
alluded to, but no area of anaesthesia could be
demonstrated.
"The radiogram (Plate VII., Fig. i) shows a
normal hip-joint, while that of the affected joint
(Plate VII., Fig. 2) shows an obliteration of
definition of the normal outline of the head and
neck of the femur. The digital fossa is filled up
with some opaque material ; and the capsule of
the joint is apparently infiltrated with some form
of deposit, which is opaque to the rays. There are
evidently very considerable changes in the joint.
^^ Fourth Case, — The next case is that of a woman.
MY OWN THEORY 6s
aged thirty-two, who attended at the Charing Cross
Hospital as an out-patient. She lives in fairly
good circumstances, earning her living as a house -
keeper. In her history she states that eight years
ago she suffered from rheumatic fever. Since that
illness she has been on several occasions laid up,
for considerable periods, with attacks of acute pain
affecting the whole of the right lower extremity.
These attacks were diagnosed and treated as
sciatica. The present trouble commenced with
pain, which at first was felt at the inside of the
knee, and afterwards in the hips and groin. The
pain gradually increased in severity, and ultimately
affected the whole limb. She describes the pain as
being throbbing and neuralgic in character. For
two years she has walked lame, and has had diffi-
culty in turning in bed and in going upstairs. The
pain is always worse at night.
" On examination, the movements of the joint
were found to be free, but semiflexion with rota-
tion inwards gave pain. Pressure above the great
trochanter, over the sciatic notch, and in the
popliteal space, gave pain. The muscles of the
gluteal region and of the thigh were wasted. The
painful areas on the surface of the limb were the
gluteal region, the posterior aspect of the thigh,
and the outer and posterior aspect of the leg as far
as the ankle.
5
66 SCIATICA : A FRESH STUDY
" By comparing the radiogram of the normal
joint (Plate VIII., Fig. i) with the radiogram of
the joint on the affected side (Plate VIIL, Fig. 2),
it will be seen how striking are the changes which
have taken place. The normal outline of the
head and neck of the femur has disappeared, and
is replaced by an irregular mass of opaque material.
Above, this mass is sharply limited internally,
where it meets the overgrown rim of the aceta-
bulum. The lower outline of the joint is also
deformed in the same way. Considerable dis-
organization of the structures forming the joint
has evidently taken place."
The fifth case is a plain mistake in diagnosis.
Finally, is it not strange that there is little or no
reference in surgical literature to special troubles
in the hip-joint apart from those of a tubercular
character and general disorders of a septic nature ^
When we consider that of all articulations in
the body the hip-joint must be the most sus-
ceptible of injury — even more so, perhaps, than
the knee, seeing that the whole weight of the
body is often unfairly thrown upon it — surely we
might expect signs of mischief more frequently
than is mentioned in the books.
May not the failure to detect disease in this
case be due to the fact of the joint lying so deep,
MY OWN THEORY 67
as Hilton says, compared with the knee, of the
troubles in which so much is made ?
Indeed, on the other hand, if we try to account
for the frequency of tubercular disease of the
hip-joint, is it not most likely due to the many
shocks the articulation suffers from violent impact
between the acetabulum and the head of the femur?
If this be so, then it is reasonable to assume
that a similar injury in a different constitution will
equally produce some amount of mischief in the
joint.
I may be allowed to add that if there be any
truth whatever in the account I have given of
my observations in cases of sciatica, it is re-
markable that the various writers on the subject
do not even mention whether they examined the
region of the hip on the affected side of their
patient or not. To my mind it is quite clear that
such an idea never entered into their heads. For
a time my sciatic cases were photographed, with
the almost universal result that patient after patient
showed clear and unmistakable evidence of wast-
ing of the hip muscles of the limb in which sciatica
was complained of. It was, as a rule, quite as
decided as one sees it in ordinary tuberculous
morbus coxae. If, then, I am justified in asserting
that there was no attempt made to find out
whether the hip-joint was affected or not, I think
68 SCIATICA: A FRESH STUDY
I am entitled to hold, in the absence of evidence
to the contrary, that the articulation was diseased.
Referring again to rheumatoid arthritis, Dr. Iron-
side Bruce has shown how easy it is to confound
that disease with sciatica. I am inclined to go
farther, and to assert they are the same disease
under different names. In its early stages, as I
have already stated, it is labelled "sciatica," especially
if it gets well ; in its later, it is called " rheumatoid
arthritis," when the X rays or pelvic deposits make
the diagnosis unmistakable. In this connection
neither Adams, nor, as far as I know, any writer
on the disease, has ever attempted to give its
complete life -history. How does the disease
begin ? Clearly the first stage is the most interest-
ing period to scrutinize, if we wish to treat it in
the hope of success attending our efforts to make
a cure. As Hilton says, the nervous arrangements
of the joints are made to warn us of danger. Are
not the pains of sciatica just such signals ? Take
the case of an aged clergyman with acute pain in
his hip, lame when walking, and, besides, sleepless
from pains in his leg. It is put down as com-
mencing arthritis in his hip-joint. Everything
seemed then to point that way; and yet to my
surprise the pain disappeared and the limb came
to be as useful as ever. Of course, I mistook his
case. It was one of sciatica, you say, and perhaps
MY OWN THEORY 69
I told the patient so ; but was not the first opinion
correct ? — the explanation being that with rest and
rational treatment the trouble in the hip-joint dis-
appeared. Had my friend been a poor working-
man, instead of a gentleman who could afford to
lie up, and had not sought advice, but had gone on
with some hard daily labour, I have no hesitation
in saying that in the course of two or three years
he would have been going about with one shoulder
hunched up and his bad leg describing the arc of a
circle instead of being propelled in a straight-
forward direction. For one ankylosed hip-joint
amongst every hundred of the rich there are prob-
ably at least ten in every hundred of the poor.
Reverting once more to Hilton and his observa-
tions on the difficulty of diagnosing disease of the
hip-joint on account of its depth from the surface,
I venture again to assert if the poor man had
suffered from an affection, shall we say ? of the
knee, the chances of his escaping permanent lame-
ness would have been ever so much greater,
because, the articulation being so very much more
superficial, means would have been applied in time
to stop the progress of the mischief; whereas in
the former case, where there was no evident
physical sign of disease, only pains coming and
going in certain positions, it was allowed to go
on unchecked, or worse, perhaps, encouraged to
70 SCIATICA : A FRESH STUDY
progress more and more in the wrong direction —
to ankylosis of the limb at the hip-joint. I do
not wish to draw too lurid a picture of sciatica,
but in the course of an unusually long professional
life, no rule of conduct has impressed itself more
on my mind than the mistaken kindness when
dealing with real disease in not facing out the
conclusions of a careful and, let me add, con-
scientious prognosis. That the quack for his own
profit should assume the role of pessimist is no
real reason why the honest practitioner should,
instead of foolishly preaching peace when there
is no peace, boldly tell his patient the truth, and
at the same time warn him of the consequences
of disobedience of orders. In this connection, as
an old hand, I may be allowed to add that perhaps
the most difficult of all rules to enforce is the
simple regimen Rest^ which, as I have said, is the
golden rule, as we shall see farther on, in early
sciatica.
CHAPTER III
TREATMENT OF SCIATICA
If a study of the true pathology of sciatica
implies some trouble in the hip-joint, then it
almost certainly follows that the first indica-
tion in the acute stage of the complaint is to
secure rest for the " inflamed " articulation. I
have endeavoured to show that the irritation in
the joint sets up a tonic contraction in the
corresponding muscles. Unfortunately for the
patient, this leads to a certain amount of restless-
ness and desire for change of position which is
difficult to resist. Like the analogous state of
things in the case of fractures, it may be necessary
to oppose the spasmodic condition by the applica-
tion of fixed splints, and by such a remedy as
morphia, given by preference hypodermically. Of
course, we must keep in view the objections to
such a form of treatment. The drug must not
be given in excess, which is a danger that need
not be incurred, seeing it can be avoided by small
and repeated doses. The drawback of inducing
71
72 SCIATICA : A FRESH STUDY
the morphia habit must ever be present to the
practitioner's mind, and yet experience has
abundantly proved that it is the cure -par excel-
lence for the frequently intense pain suffered
at the onset of an attack. Acupuncture and
blisters may be used, and seem in some hands to
have been beneficial. But with others these means
have failed to be of decided benefit, and I confess
to feeling personally doubtful of their good effects.
Massage and electricity, it is generally allowed,
are contra-indicated at an early period of the
illness, although the strongest advocates for the
seat of the complaint being in the hip-joint must
allow that when the inflammatory period is past
these remedies are of the greatest service. In the
way of constitutional treatment, antigouty and
antirheumatic remedies are recommended equally
from both points of view. The use of oil of
turpentine has undoubtedly proved of benefit,
some say for its purgative effects. But may not
this be the result of its diuretic action } This
would hold good whether effusion was present
in the nerve-sheath or within the capsule of the
joint itself.
Speaking of rest and relief from pain, I am
inclined to think that of late it has been too
much the practice to give the salicyl compounds
too freely and those of opium too little. As I
TREATMENT OF SCIATICA 73
have said, we all know the dangers of the
morphia habit, and one cannot be too careful in
using such a too-ready weapon in combating
pain and yet making sure of due precautions
and limiting its use to the surgeon's own hands,
and his alone. Insisting on the absolute need of
asepsis, there is no one remedy to compare with
the hypodermic application of morphia for efticacy
in this complaint. At the same time it is true
that sufficiently large doses of salicylate of sodium
(I have myself given 80 grains at one time
without any bad effects) or of aspirin are often
valuable. May I venture to recommend a com-
bination of morphia, salicylates, bromide of potas-
sium, and chloral, as a useful prescription ? With
such a jumble of remedies, we avoid the risk of
giving a too large quantity of any single one of
these dangerous drugs, though, of course, the
formula errs, like many others, in affording us
no clear indication of the real results of any one
medicament in the lot.
With regard to the indications of treatment in
the early or acute stages. What had best be
done when the disease is less severe, and has
become chronic }
First, the constitutional conditions have to be
carefully considered ; rest has still to be thought
of, while a certain definite amount of exercise
74 SCIATICA : A FRESH STUDY
must be arranged, and the diet has to be
regulated. In connection with a proper diet,
I wish to point out that in many, if not in most,
cases of sciatica, as the tables I have given show,
there is the predisposing element of the constitu-
tional dyscrasia of gout or rheumatism, or both
together. What these common complaints pre-
cisely stand for is a very moot point.
Speaking generally, they may be described as
errors of metabolism, and we cannot be far wrong
in assuming that of all the internal organs at fault
the chief sinner is the stomach ; and yet this
viscus is more sinned against than sinning. And
so the regulation of food and beverages should
play a very important part in the treatment of
sufferers from sciatica. Dogmatism on most
disputed points is often only a proof of ignorance,
and to no subject does this obiter dictum apply
more frequently than in rules for diet. For
example, it is said that much meat, more
especially red meat, is to be avoided as an
article of food in gout. A very intelligent
butcher in one of the largest cities of the Empire
told me he was acquainted with almost every
fellow-flesher in the town, and that he did not
know one single individual who suffered from
gout ! Add to this that I have seen much
benefit from the so-called Salisbury diet in
TREATMENT OF SCIATICA 75
rheumatic gout. Red meat per se is not in-
jurious, but in my humble opinion red meat
plus a too free use of starchy and saccharine
substances, is frequently a genuine cause of gout.
In other words, over-eating is bad. It is often
a case more for regulating the quantity rather
than the quality of the food to be allowed.
Many years' experience gives me the right to
be dogmatic on the question ot stimulants. I do
not hesitate to say that more gout is brought on,
including attacks of gouty sciatica, by the use
of alcohol than by all other general mal-influences
combined. Therefore, I strongly advise that beer,
wine, and whisky (they are injurious, perhaps,
in the order I have named) be peremptorily
forbidden.
When these matters are settled, then comes the
question of drugs and mineral waters. Assuming
that in the early stages the usual pharmacopoeial
remedies, whether tonic or alterative, have been
administered secundum artem, then the question of
having recourse to some health resort naturally
arises. The particular spa to select has to be well
considered. My experience would lead me to
advise, in gouty or rheumatic patients, one of the
many sulphur spas in our own country, or Switzer-
land in summer ; Helouan, or, it may be, those
of the Cape or New Zealand in winter.
76 SCIATICA : A FRESH STUDY
As regards baths, distinctly hot baths, prefer-
ably sulphur, peat, or mud, are often, I have
found, of great advantage. Electricity, whether
in the form of high-frequency or the continuous
current, may prove of service, and ought to be
tried in obstinate cases. The Faradaic form had
best be avoided. Radiant heat is a highly potent
remedy, open, however, to the objection that even
when carefully applied it is apt to bring on general
feverishness, which I have known to leave bad
effects on a particular patient.
Although I have said that Sir William Gowers
is too ready to assume the presence of fibrositis as
likely to spread to the nerves, and so bring on
neuritis, yet I am quite at one with Professor
Stockman when he states that such a process or
degeneration is apt to affect the muscular structures,
more particularly those connected with diseased
joints.
In the Lancet for April 13, 19 13, p. 104, there
is an annotation referring to the anatomical basis
for the professor's views. It goes on to mention
the researches of Mr. K. W. Goadby, who has
found a probable microbic explanation of fibrositis.
I mention the contributions of these authors as
valuable additions to a true pathology of chronic
sciatica, because they afford logical ground for
massage in that complaint.
TREATMENT OF SCIATICA 77
For more than forty years I have been empiri-
cally of the opinion of the great value of that
remedy in suitable cases of a chronic kind. In
agreement with modern views as to the good
effects of massage in recent fractures, and its
application even when rest is absolutely demanded,
we must now allow that massage may be care-
fully and cautiously applied to recent cases of
sciatica. But much skill will be needed on the
part of the operator, and all forcible manipulations
strictly avoided.
As a parting word, I venture to predict that
a calm, unbiassed consideration of the true prin-
ciples of treatment in sciatica, combined with a
study of the cases, the notes of which I have given
as they were roughly written down at the moment,
will go a long way to show, if not absolutely prove,
that some trouble, great or small, in the hip-joint
squares better with the facts as observed than the
present orthodox view that sciatica is primarily a
neuritis of the corresponding nerve.
If this be so, then we shall be able to found our
practice on a sounder pathology, and be less likely
to be led away by reports of cures, the results of
over-hasty observations, and supposed to have
been brought about by the use of remedies which
really and truly had no logical connection whatever
as cause and effect.
78 SCIATICA : A FRESH STUDY
In conclusion, sciatica, with the exception of
some of the commonest ailments, however bad it
may appear at first, is, perhaps, the most suscep-
tible of all complaints to the vis medicatrix
naturae when not foolishly thwarted but confidently
trusted.
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82 SCIATICA : A FRESH STUDY
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JMerve to 3enuxru^rnbtvsricr5ie3-
LUMBO-SACRAL PLEXUS
Intei-tOT- DoplifaaL
Artie ulArfiravnches
to tJTg Hi p-j tnJTt^
Mcrvc to 5twrt beui
^ ^Biceps
PLATE II.
S.I. a .3.
CUTANEOUS NERVE SUPPLY : POSTERIOR.
PLATE III.
GcnilD— crxxraL,
jL.i.2. -
GxtemiJ.
L.2.3- ,
L.2.5- \
L.2.3.
L.I
Ircbzrmd
CUTANEOUS NERVE SUPPLY : ANTERIOR
APPENDIX I 83
To show the connections between the cutaneous nerve-
supply of the lower extremity and the nerve-supply of
the hip-joint, a description of the origins of these nerves
is necessary. As it is the posterior aspect of the joint
and limb that concerns us here, we shall confine ourselves
to the sacral plexus.
THE SACRAL PLEXUS
It is formed by part of the anterior primary division of
the fourth lumbar, the whole of the anterior primary
divisions of the fifth lumbar and the first sacral, and
portions of the anterior primary divisions of the second
and third sacral nerves.
Sympathetic Connections.
Each of these nerves is connected to the lumbar or
pelvic sympathetic by grey rami communicantes ; and
white rami communicantes pass usually from the third
and sometimes from the second and fourth sacral nerves
to the pelvic plexus of the sympathetic.
Origin from the Spinal Cord and Canal.
These nerves arise from the spinal cord opposite the
spines of the eleventh to the twelfth dorsal vertebrae,
and proceeding downwards emerge from the spinal canal,
the lumbar nerves at the intervertebral foramina between
the fourth and fifth lumbar vertebrae and the sacrum,
and the sacral nerves at the anterior sacral foramina.
Formation of the Plexus.
The branch of the fourth lumbar nerve appears at the
inner border of the psoas magnus, internal to the obturator
84 SCIATICA : A FRESH STUDY
nerve, and splits behind the iliac vessels into ventral and
dorsal divisions. The anterior primary divisions of the
fifth lumbar, after descending over the ala of the sacrum,
divides into tv^o also, the branches of the fourth joining
them to form the lumbo-sacral cord. The first and
second sacral nerves pass horizontally outwards and divide
into ventral and dorsal branches, w^hilst the third sacral
breaks up into upper and lower branches, the former
alone entering into the sacral plexus. These all converge
towards the lower part of the great sacro-sciatic foramen
to form a broad triangular band, from the anterior and
posterior surfaces of which the nerves to the neighbour-
ing structures arise, and which is continued into the
buttock below the pyriformis as the great sciatic nerve.
Distribution of the Plexus.
Origin.
Ventral. Dorsal.
Nerve to pyriformis ... ... — S., I, 2.
Superior gluteal — is'i
Inferior gluteal ... ... — i c ' \
^ I b.y I, 2.
Nerve to quadratus femoris and / L., 4, 5,
inferior gemellus IS., i.
Nerve to obturator internus and/ L., 5.
superior gemellus ... ... IS., 1,2.
Small sciatic ... ... ... S., 2, 3. S., i, 2.
Internal popliteal] n* [ —
Great sciatic ^ ^ ^-j i> 2, 3. j
1 External popliteal — t ^"^ ^^ ^'
APPENDIX I 85
Course of the Branches of the Plexus.
The superior gluteal nerve arises from the dorsal
divisions of the fourth and fifth lumbar and first sacral
nerves. It passes out of the pelvis at the great sacro-
sciatic foramen above the piriformis along with the
gluteal artery, immediately dividing into a superior and
an inferior branch. The former accompanies the upper
branch of the deep division of the gluteal artery and
supplies the gluteus medius. The latter crosses the
gluteus minimus with the lower branch of the artery,
and, after sending branches to gluteus medius and gluteus
minimus, perforates the fore-part of the latter to end in the
tensor fasciae femoris.
The inferior gluteal nerve arises from the dorsal
divisions of the fifth lumbar and first and second sacral
nerves. It is closely associated with the small sciatic
nerve at its origin. It emerges from the pelvis below
the pyriformis, superficial to the great sciatic nerve, and
divides up into a number of branches for the supply of
the gluteus maximus.
The nerve to the pyriformis arises from the dorsal
divisions of the first and second sacral nerves. It is occa-
sionally double. It enters the deep surface of the muscle.
The small sciatic nerve arises from the ventral divisions
of the second and third sacral and the dorsal divisions of
the first and second sacral nerves. It passes out of the
pelvis through the great sacro-sciatic foramen below the
pyriformis. It descends beneath the gluteus maximus,
along with the sciatic artery, down the back of the thigh
over the long head of the biceps. It lies under the
fascia lata till it pierces the popliteal fascia opposite the
86 SCIATICA : A FRESH STUDY
knee-joint. Its terminal branches supply the skin of the
calf, accompanying the short saphenous vein, and com-
municating with the external saphenous nerve.
This nerve is entirely sensory, supplying the skin
of part of the perineum, lower part of the buttock^ back
of the thigh, and upper portion of the leg. Its branches
consist of —
Gluteal are two or three filaments which turn upwards
over the inferior border of the gluteus maximus to supply
the skin over the lower and outer part of the muscle.
Perineal turn inwards below the ischial tuberosity to
supply the upper and inner part of the thigh. The
largest of these is the inferior pudendal^ which curves
forwards below and in front of the ischial tuberosity,
pierces the fascia lata, and is continued on to the outer part
of the scrotum, its terminal filaments communicating with
the superficial perineal and inferior haemorrhoidal nerves.
Femoral arise from both sides of the nerve beneath the
fascia lata. They are numerous, and supply the skin of
the back of the thigh.
The nerve to the quadratus femoris arises from the
ventral divisions of the fourth and fifth lumbar and first
sacral nerves. It leaves the pelvis through the great sacro-
sciatic foramen below the pyriformis, and runs down in
front of the great sciatic nerve, the gemelli, the tendon of
the obturator internus on the back of the capsule of the
hip-joint, to which it sends a filament, and ends in the
deep surface of the quadratus femoris, after giving a branch
to the gemellus inferior.
The nerve to the obturator internus is derived from the
ventral divisions of the fifth lumbar and first and second
sacral nerves. Appearing in the buttock at the lower
APPENDIX I 87
border of the pyriformis, it lies below the great sciatic
nerve on the outer side of the pudic vessels. It gives
off here a branch to the gemellus inferior, and then turns
over the ischial spine, through the small sacro-sciatic
foramen, virith the pudic vessels to its inner side to enter
the pelvic surface of the muscles.
The great sciatic nerve is the largest nerve in the body.
It directly supplies the muscles of the back of the thigh
and the hip-joint, w^hilst its branches give nerves to all the
muscles below the knee, to the greater part of the integu-
ment of the leg and foot, and to the other joints of the
lower extremity.
The greater part of the sacral plexus is continued into
the great sciatic nerve, which divides at a variable level in
the thigh into internal popliteal or tibial nerve, and ex-
ternal popliteal or peroneal nerve. In about 15 per cent,
of cases these two arise independently from the plexus, and
in these the external popliteal usually pierces the pyri-
formis. On removal of the sheath investing the nerve,
the two branches can be traced up to their origin from
the plexus, when the external popliteal is seen to arise
from the dorsal divisions of the fourth and fifth lumbar
and first and second sacral, and the internal popliteal from
the ventral divisions of the fourth and fifth lumbar, and
first, second, and third sacral nerves.
At its commencement it is a thick band about J inch
broad, consisting from within outwards of the nerve to
the hamstrings, tibial, peroneal, and nerve to short head
of biceps. Emerging from the great sacro-sciatic foramen
between the pyriformis and the gemellus superior, it passes
down to the thigh accompanied by the sciatic nerve, and
comes nervi-ischiadic artery, which runs for some dis-
88 SCIATICA: A FRESH STUDY
tance in its substance. It descends in the hollow between
the great trochanter and the tuberosity of the ischium
along the back of the thigh to about its lower third, where
it divides into its two terminal branches.
In its course it rests on the ischium, the nerve to the
quadratus femoris, superior gemellus, obturator internus,
inferior gemellus, quadratus femoris, and adductor magnus.
It lies deep to the gluteus maximus and the long head
of the biceps, which is closely approximated to the
lower edge of the former muscle. The nerve, therefore,
is well covered and protected from dangers from without,
such as the effects of exposure, cold, and strain. Experi-
ments on cadavera have proved that it is only in extreme
flexion of the lower limb on the abdomen that there
is the slightest straining of the fibres.
Origin and Course of Nerves to Hip-Joint —
Posterior Aspect.
1. The branch from the nerve to quadratus femoris is
derived from the fourth and fifth lumbar, and the first
sacral spinal cord segments. It leaves the nerve as it lies
on the back of the capsule of the hip-joint beneath the
external rotators of the thigh. This articular branch
passes close to the posterior border of the acetabulum to
enter the back of the joint. It may pass directly from the
sacral plexus to the articulation.
2. The branches from the great sciatic nerve are also
divided from the fourth and fifth lumbar and the first
sacral spinal cord segments. They are filaments which
arise from the upper and front part of the nerve near its
origin, perforating the posterior part of the fibrous capsule.
They often arise directly from the sacral plexus.
APPENDIX II
CASES OF SCIATICA OBSERVED
AT STRATHPEFFER FROM MAY, 1889,
TO OCTOBER, 1912
Notes of Cases Observed.
No. Sex. Age.
1. Female. 80. Gouty condition of ankles ; eyes also
affected ; much wasting of glutei ;
slight wasting of muscles of thigh.
2. Female. 66. Pelvic deposit ; much wasting of
glutei.
3. Female. 70. Free from pain on lying down, pain
in going downstairs.
4. Female. 50. Polyarticular gout ; much tender-
ness on pressure over the capsule of
hip-joint.
5. Male. 68. Gout in knees — family rheumatic ;
fulness and marked tenderness over
the hip-joint.
6. Female. 46. Arm also affected ; no limitation ot
circumduction, and no tenderness
on pressure over the hip-joint ; can-
not put a foot under her when bad.
7. Female. 60. Knees rheumatic ; tenderness on
pressure over hip-joint.
89
90 SCIATICA : A FRESH STUDY
No. Sex.
8. Male
Age.
45.
Internal rotation at hip-joint markedly
limited ; wasting of glutei con-
siderable; very distinct fulness over
the articulation, and decided tender-
ness on pressure.
9. Female. 73. Internal rotation limited in extent ;
external rotation more so. Tension
of the muscles in front of hip-joint.
10. Female. — Lameness in affected leg after
walking.
11. Male. 71 Signs of gouty neuralgia from cold ;
external rotation of hip-joint limited ;
much wasting of glutei ; slight ten-
derness on pressure over the capsule.
Rheumatic gout in arm and hip,
12. Female. 49.
13, Female. 41.
and
14. Male. 56.
and some wasting of glutei,
clear tenderness on pressure over
the capsule of the hip-joint ; an
acute attack.
Rheumatism in shoulder and leg —
mother rheumatic ; external rotation
of hip-joint slightly affected ; marked
wasting of glutei, with complete
obliteration of the folds of the
nates ; feels as if she would like her
leg pulled out.
Gout in other joints ; flexion of leg
at one hip-joint imperfect ; no dis-
tinct wasting of glutei or obliteration
of folds of nates in either leg ; a
little fulness on his right side. Pelvic
deposits. Everts the legs, and can-
not, though given to hunting, get
on horseback ; both sides affected.
Double case.
APPENDIX II
91
No. Sex.
15. Male.
16. Male.
17. Male.
18. Male.
1 9. Female.
20. Female.
21. Male.
Age.
46.
56.
70.
62.
60.
52.
56.
22. Male.
23. Male.
55.
Toe-joii. affected ; imperfect
flexion of hip-joint ; marked ten-
derness on pressure over the capsule
in front.
Some difficulty in rotating the limb
internally.
Rheumatic ; has had gout in his
left foot and knees ; some oblitera-
tion of folds of nates ; no tenderness
on pressure over the hip-joint.
No history of gout or rheumatism ;
never had lumbago ; some tender-
ness on pressure over the hip-joint.
Both legs affected. Right ^ flexion
at hip-joint much restricted ; in-
ternal rotation not affected ; external
much so ; great tenderness on pres-
sure over the capsule. Left much
the same ; external rotation incom-
plete, and some obliteration of folds
of nates, but tenderness on pressure
over hip-joint not so marked as on
the opposite side.
Gout in fingers ; internal rotation
distinctly affected.
No signs of gout or rheumatism ;
slight affection of external rotation
at the hip-joint ; no wasting of
glutei ; no tenderness on pressure
over the capsule. After sitting long
must help the affected leg over its
neighbour.
No notes.
Flexion at the hip much affected.
92 SCIATICA : A FRESH STUDY
No. Sex.
24. Female.
Age.
48.
Rheumatism in all her joints. Both
sides affected to much the same
degree ; flexion at the hip-joints
markedly so, especially on the left ;
also external rotation ; marked ten-
derness on pressure over the capsule
on both sides.
25. Male. 69. Mother rheumatic ; no tenderness
on pressure over the hip-joint.
26. Male. 35. Wasting of the glutei muscles, and
considerable tenderness on pressure
over the hip-joint.
Has had previous attacks of sciatica.
Rheumatic gout ; mother gouty ;
occasionally attacks of sciatica.
Has had acute gouty sciatica five
years ago.
Internal and external rotation of
hip-joint much affected ; must help
bad leg over the other.
31. Female. 31. Grandfather on both sides gouty;
never had lumbago. Has been in
bed for some months. Cannot cross
the affected leg over its neighbour.
Gouty for some years ; has had
lumbago. External rotation at hip-
joint considerably affected ; internal
less so ; flexion pretty complete ;
decided tenderness on pressure over
the capsule.
Shoulders been bad ; external rota-
tion very deficient at the hip-joint ;
trouble getting into erect position.
27. Male.
28. Female.
29. Male.
30. Male.
65.
56.
56.
75-
32. Male. 61,
33. Female. 50.
APPENDIX II
93
No. Sex.
34. Male.
36. Male.
37. Male.
38. Male.
4 1 . Female.
42. Female.
Age.
35. Male. 60.
42.
34.
62.
39. Female. 53.
40. Female. 57.
40.
55-
Flexion, internal and external rota-
tion all right ; distinct wasting of
glutei, and tenderness on pressure
over the hip-joint.
Rheumatic gout ; external rotation
at hip-joint very defective ; flexion
and internal rotation good ; some
wasting of glutei, and some tender-
ness on pressure over the capsule ;
complains of much pain.
Grandfather gouty and mother rheu-
matic ; both legs affected. Now
recovered.
Arms been troubled ; great tender-
ness on pressure over the hip-
joint.
Nails brittle, and has had lumbago ;
flexion at hip-joint deficient ; some
wasting of glutei, and considerable
tenderness on pressure over the
capsule.
Flexion and external rotation free ;
internal rotation rather deficient at
the hip-joint ; marked tenderness on
pressure over the capsule.
Toes and knees bad ; never had
lumbago ; movements at hip-joint
free ; slight tenderness on pressure
over the capsule.
Some tenderness on pressure over
the hip-joint.
No notes.
94
SCIATICA : A FRESH STUDY
No. Sex.
43. Female.
Age.
66.
44. Male. 67.
45. Male.
46. Female.
63.
47. Male. 53.
48. Female. 65.
49. Female.
50. Male.
64.
47.
Flexion slightly affected ; internal
rotation more so at hip-joint ;
decided wasting of glutei and ob-
literation of folds of nates ; much
tenderness on pressure over the cap-
sule.
Flexion and internal rotation free.
External rotation decidedly affected
at hip-joint ; slight tenderness on
pressure over the capsule.
Gout in toe. Tenderness on pres-
sure over the head of the rectus
muscle.
Motions at hip-joint little affected ;
slight tenderness on pressure over
the capsule ; worse at night, bad
also in the morning when she first
gets out of bed.
Flexion and external rotation good,
but internal rotation hampered at
hip-joint; some wasting of glutei,
distinct obliteration of folds of nates,
and decided pain on pressure over
the capsule.
Some wasting of glutei and distinct
obliteration of folds of nates ; no
tenderness on pressure over the hip-
joint. This case was described as
neuritis, not sciatica.
No notes.
Arms and shoulders been pained ;
flexion and internal rotation of hip-
joint free, but external rotation
much affected ; slight wasting of
APPENDIX II 95
No. Sex. Age.
glutei and considerable obliteration
of folds of nates ; a little tenderness
on pressure over the capsule.
51. Male. 37. No rheumatism, no lumbago ;
flexion, internal and external rota-
tion free ; distinct wasting of glutei
and obliteration of folds of nates;
slight tenderness on pressure over
capsule.
52. Male. 55. Both legs affected; shoulder been
troublesome ; has had lumbago.
Flexion and external rotation fairly
good, but external rotation bad on
right and decidedly affected on left
at the hip-joints. On the left side
much wasting of glutei and oblitera-
tion of folds of the nates ; very
decided tenderness on pressure over
both hip-joints.
53. Female. 51. Flexion clearly affected, with some
deficiency in internal and external
rotation in hip-joints ; slight wasting
of glutei and distinct obliteration of
folds of nates, with some tenderness
on pressure over the capsule.
54. Male. 67. Rheumatism in knees ; wasting of
muscles of leg, and evidence of
pelvic deposits ; has had lumbago.
Flexion complete, but internal and
external rotation deficient ; no wast-
ing of glutei ; no apparent oblitera-
tion of folds of nates.
55. Male. 72. Has had lumbago ; hip-joint disease
at age of 15. Marked tenderness
on pressure over the joint.
96 SCIATICA: A FRESH STUDY
No. Sex. Age.
56. Female. 62.
57. Female. 72.
58. Male. 61.
59. Female. 50.
60. Female. 47.
61. Male. 30.
62. Male. 56.
63. Female. 50.
64. Male. 59.
65. Male. 60.
66. Female. 60.
Flexion and internal rotation de-
ficient ; external rotation free ; great
tenderness on pressure over the hip-
joint ; cannot move the leg at night.
Mild case — did well.
Elbows and knee been bad ; marked
sv^^elling and pain when lying on
the affected side.
Shoulders, knuckles, and big toe
been bad ; lies on her back with
affected leg straight out and sound
one flexed.
Has had lumbago.
Some wasting of glutei ; distinct
obliteration of folds of nates, with
marked tenderness on pressure over
the hip-joint. Pain on standing and
when he lies on the affected
side.
Neuralgia ; has had lumbago. Cir-
cumduction perfect ; wasting of
glutei, and some tenderness on pres-
sure over the hip-joint.
Has had lumbago ; a little tender-
ness on pressure over the hip-joint.
Slight case, one day ill.
Has had lumbago. Exactly the
same as No. 62.
Rheumatism in arms and small toes.
Has had lumbago. Faint tender-
ness on pressure over the joint.
Big toe -joint ; leg wasted and
lame.
APPENDIX II
97
No.
67.
Sex.
Female.
Age.
70.
68.
Male.
53.
69.
Male.
54.
70.
Male.
65.
71.
Male.
61.
72. Male. 48.
73. Female. 54.
74. Male. 48.
Has had lumbago. Flexion imper-
fect, external rotation slightly so ;
no tenderness on pressure over the
hip-joint.
No notes.
Rheumatic ; has had lumbago. Dis-
tinct wasting of glutei ; slight
obliteration of folds of nates ; diffi-
culty in tying his shoe-laces.
Shoulders troublesome ; both hip-
joints bad.
Hereditary rheumatism ; has had
lumbago. Cannot lie on the affected
side.
Flexion much affected at hip-joints ;
considerable wasting of glutei ;
slight obliteration of folds of nates ;
much tenderness on pressure over
the hip -joint. A gamekeeper ;
could not move in bed for two
weeks.
Hand, arms, and shoulders affected ;
mother rheumatic ; circumduction
perfect ; no tenderness on pressure
over the hip-joint ; never actually
lame ; came on suddenly, like tooth-
ache.
Gout in shoulder ; has had lumbago.
Considerable wasting of glutei ;
great tenderness on pressure over
the hip-joint ; pain comes and goes
quietly.
75. Male. 60. Ankylosis
great deposits on pelvis.
7
98 SCIATICA : A FRESH STUDY
No. Sex.
76. Male.
Age.
76.
^^, Male. 60,
78. Male. 50,
79. Female. 50.
80.
Female.
52.
81.
Male.
60.
82.
Male.
60,
83-
Female.
50,
External and internal rotation
markedly defective at the hip-joint ;
distinct tenderness on pressure over
the capsule.
Has had lumbago. Internal rota-
tion deficient ; external doubtful at
hip-joint ; decided wasting of glutei,
and obliteration of folds of nates ;
also distinct tenderness on pressure
over the capsule, where also there
is a local heat with decided fulness
over the capsule in front.
Has had lumbago. Circumduction
in hip-joint perfect ; some wasting
of glutei ; tenderness on pressure
over the capsule well marked ;
pain comes and goes quickly.
Flexion affected, extension and
internal rotation still more in con-
nection with hip-joint ; distinct
wasting of glutei, with well-marked
tenderness on pressure over the
capsule.
Slight case, cured by rest.
Has had lumbago, said to be rheu-
matism of right hip, one twinge
nearly causing fainting.
Never had lumbago ; lameness after
a week's golfing ; pain at level of
trochanter.
Rheumatism in both arms ; flexion,
internal rotation affected at hip-
joint ; considerable wasting of glutei,
and obliteration of folds of the
APPENDIX II
99
No.
Sex.
Age.
84. Female. 42.
85. Female. 56.
86. Female. 65.
87.
88.
Male.
Male.
42.
50.
89. Male. 45.
nates; very marked tenderness on
pressure over the capsule.
Internal rotation of the hip-joint,
much affected ; very marked ten-
derness on pressure over the capsule.
Cannot extend her right elbow ;
circumduction of hip-joint not free
(a little stiffness) ; wasting of glutei,
with considerable obliteration of
folds of nates; well marked tender-
ness on pressure over the capsule ;
cannot turn in bed, or put her feet
in slippers.
Flexion at the hip-joint a little
imperfect ; internal and external
rotation complete ; some wasting of
glutei, and distinct obliteration of
folds of nates ; no tenderness on
pressure over the capsule. Interest-
ing case ; getting well before I saw
her. Was quite cured.
Carpenter ; marked wasting of glutei.
Both legs affected. Flexion ; in-
ternal and external rotation at the
hip-joint much affected ; some wast-
ing of glutei ; well-marked tender-
ness on pressure over the capsule in
both limbs.
Had rheumatic fever. Flexion and
external rotation not much wrong,
but internal rotation considerably
affected ; much wasting of glutei ;
distinct tenderness on pressure over
the capsule.
100 SCIATICA : A FRESH STUDY
No. Sex. Age.
90. Male. 62.
91. Female. 50.
92. Female. 65.
93. Female. 56.
94. Male. 65.
95. Male. 45.
96. Female. 64.
97. Female. 65.
Rheumatism in shoulders ; some
wasting of glutei, and distinct
obliteration of folds of nates, with
considerable tenderness on pressure
over the capsule.
Circumduction at hip-joint perfect;
marked tenderness on pressure over
the joint.
Rheumatism in head and back ;
some difficulty in flexion at both
hip-joints, with a little change in
the folds of nates, and slight tender-
ness on pressure over the capsule.
Has had lumbago. Flexion at hip-
joint imperfect ; marked tenderness
on pressure over the capsule. Has
to help her leg up in getting into
a carriage.
Some wasting of glutei, with obliter-
ation of folds of nates; slight ten-
derness on pressure over the hip-
joint.
Flexion at hip-joint rather imper-
fect ; slight wasting of glutei ; some
pelvic thickening ; pain in the back
of leg ; improved by treatment.
Has had lumbago. Flexion and
internal rotation at hip-joint much
affected ; very marked tenderness on
pressure over the capsule. Cannot
put the right over left leg.
Sister gouty. Rheumatism in fingers
and neck ; flexion imperfect at hip-
joint.
APPENDIX II
lOI
No.
98.
99-
100.
Sex.
Male.
Female.
Male.
103. Male.
105.
106.
Male.
Age.
56.
60.
61.
loi. Female. 52.
102. Female. 66.
60.
104. Male. 40.
Female. 60.
60.
Has had lumbago. Rheumatism in
arms and legs ; flexion and internal
rotation affected at both hip-joints.
No notes.
Gout in fingers ; distinct tender-
ness on pressure over the hip-joint.
Flexion at hip -joint somewhat
affected ; distinct tenderness on
pressure over the capsule.
Has had lumbago. Some pain'
and resistance on rotation of limb
at the hip-joint ; difficulty in lift-
ing legs.
Rheumatism in shoulders and fore-
arm ; internal rotation markedly
imperfect, external less so ; flexion
perfect at hip-joint ; much wasting
of glutei, and obliteration of folds
of nates, with marked tenderness
on pressure over the capsule.
Rheumatism in arms ; has had
lumbago ; considerable wasting of
glutei, and obliteration of folds
of nates ; some tenderness on
pressure over the hip-joint.
Has had lumbago. Decided ten-
derness on pressure over both hip-
joints ; double sciatica.
Heberden*s nodes ; uric acid gravel ;
at hip-joint circumduction perfect ;
slight obliteration of folds of nates ;
no tenderness on pressure over the
capsule. A mild case.
I02 SCIATICA : A FRESH STUDY
No. Sex.
107. Male.
Age.
69.
108. Male.
109. Female.
no. Female.
111. Female.
112. Male.
63.
67,
39.
80.
53-
^13-
Female.
60.
114.
Female.
52.
115.
Female.
62.
116.
Male.
53.
117.
Female.
46.
Flexion impaired ; internal rota-
tion more, and external still more,
affected at hip-joint ; marked wast-
ing of glutei ; some obliteration of
folds of nates ; doubtful tenderness
on pressure over the capsule. Had
a limp, which he lost.
Father rheumatic. Some wasting
of glutei, as also of muscles of
thigh.
Circumduction at hip-joint nearly
perfect ; decided tenderness over
the capsule.
Has had lumbago.
Internal rotation at hip -joint
affected, but not flexion or internal
rotation. A doubtful case of
sciatica.
Has had gout, but not lumbago.
Slight deficiency of external rotation
at hip-joint, with wasting of glutei
and obliteration of folds of nates ;
slight tenderness on pressure over
the capsule. Regained complete
circumduction.
No notes.
Sudden attack ; regained complete
circumduction at hip-joint.
No objective sign of any kind.
Knees rheumatic ; pain on walk-
ing ; decided tenderness on pres-
sure over the hip-joint.
Could not lift right hand
pam
APPENDIX II
103
No.
Sex.
118. Male.
Age.
58.
119. Female. 72.
120. Female. 55.
121. Female. 44.
122. Female. 70.
123. Male. 62.
124. Male. 75,
inside hip -joint ; flexion there
affected to a certain extent, ex-
ternal rotation more so.
Has had lumbago.
feet ;
joint,
bed.
Flexion per-
extension painful at hip-
worse on getting into
Flexion and extension both affected
at hip-joint. Has been in bed six
days. Got quite well.
Father gouty. Internal and ex-
ternal rotation at hip-joint some-
what affected ; some wasting of
glutei ; some tenderness over cap-
sule ; complains of pain in her
buttock and difficulty in moving
her leg.
Rheumatism in legs and arms.
Slight difficulty in internal rotation
at hip-joint ; marked tenderness on
pressure over the capsule. Left
much better.
Gout in toe-joint. Flexion at hip-
joint distinctly affected with wast-
ing of glutei and obliteration of
folds of nates ; much tenderness on
pressure over the capsule ; in-
definite pelvic deposit.
Rheumatism in knees and ankles ;
has had lumbago. Slight trouble
in flexion at the hip-joint ; tender-
ness on pressure over the capsule ;
numbness down the leg.
Much gout in knees and shoulders.
104 SCIATICA : A FRESH STUDY
No.
125.
Sex.
Female.
Age.
62.
126.
Female.
40,
127.
Female.
70.
128.
Female.
70.
129.
Female.
54.
130.
Male.
40,
131.
Male.
38.
132.
Female.
60.
133.
Female.
70,
134.
Female.
32.
135.
Male.
40.
136.
Male.
35.
137.
Female.
54.
138.
Male.
45.
139-
Male.
65.
140.
Male.
57.
141.
—
—
142.
Male.
57.
143. Male. 41,
Rheumatism in left shoulder ;
knuckles thickened. Flexion and
internal rotation much affected at
hip-joint, with wasting of glutei
and obliteration of folds of nates ;
marked tenderness over the cap-
sule ; complains only of her knees.
Gouty eczema.
Has had lumbago.
Fourteen years ill. Both legs
affected.
Diabetic ; has had lumbago.
Has had lumbago. Difficulty in
turning over when lying down ;
decided tenderness on pressure over
the hip-joint.
Has had lumbago.
Gout in toes ; altogether lame.
Complains of weakness in her back.
Gout ; rides a good deal.
A baker ; shoulder rheumatic.
No notes.
Heberden's nodes.
Has had lumbago.
External rotation imperfect.
No improvement.
No notes.
Brothers rheumatic. Decided
tenderness on pressure over the
hip-joint.
Two years ill ; will not take rest.
APPENDIX II
105
No.
Sex.
Age.
144.
Male.
28.
Knees and ankle affected.
145.
Male.
63.
Gouty eczema.
146.
Female.
54.
Left knee rheumatic ; rheumatism
in shoulders ; has had lumbago.
147-
Female.
40.
Distinct tenderness on pressure
over the hip-joint.
148.
Male.
54.
Acute case.
149.
Male.
47-
Tenderness on pressure over hip-
joint, which disappeared under
treatment.
150.
Female.
75.
Rheumatic.
151.
Female.
52.
Been three years ill ; seemed to
be a case of rheumatoid arthritis.
Father and mother rheumatic.
152.
Male.
62.
Both legs affected.
153-
Male.
62.
Decided tenderness on pressure
over the hip-joints.
154.
Male.
72.
Uric acid gravel ; decided tender-
ness on pressure over the hip-joint.
155.
Male.
54.
Both legs affected.
156.
Male.
56.
Both sides affected ; has had lumx-
bago.
157-
Male.
30.
Been six years ill. Rheumatism
in shoulders and neck ; marked
tenderness on pressure over both
hip-joints.
158.
Male.
56.
Gout in hands and feet.
159.
Male.
29.
Five years. Slight gout -, re-
covered.
160.
Male.
67.
Slight vv^asting of glutei ; no decided
tenderness on pressure.
io6 SCIATICA: A FRESH STUDY
No.
i6i.
162.
163.
164.
tex,
Male.
Female.
Female.
Male.
Age.
40.
53-
53-
38.
165. Male. 50.
166.
Male.
70.
167.
Male.
46.
168.
Male.
50.
169.
Female.
55.
170.
Male.
40.
171.
Female.
65.
172.
Female.
30.
173.
Female.
53.
174.
Male.
44.
175.
Male.
25.
176.
Male.
36.
Has had lumbago ; operated on
afterwards, and adhesions said to
be found.
Rheumatic gout.
Nerve stretched fourteen years ago.
Considerable tenderness on pres-
sure over hip-joint ; has enlarged
lymphatic glands in neck.
Has had lumbago ; no evidence of
gout. Nervous.
History of gout ; double sciatica.
Knees rheumatic ; distinct tender-
ness on pressure over the hip-joint.
Rheumatism in arms and pain in
toes. Had eczema when a boy.
Marked tenderness on pressure
over the hip- joint.
Shoulder and mucous membranes
of nose affected.
Three months ill. Shoulder
affected ; eczema last year.
Much wasting of leg ; distinct
tenderness on pressure over the
hip-joint.
Pain in walking.
Glutei much relaxed ; slight tender-
ness on pressure over the hip-joint.
Great wasting of glutei.
Great wasting of glutei ; no
tenderness on pressure over the
hip-joint 5 pain below the knee in
golfing.
APPENDIX II
107
No.
177.
Sex.
Male.
Age.
43.
Toes swollen, and cannot shut his
hands.
178.
Male.
70.
Lame.
179.
Male.
29.
Very marked tenderness on pres-
sure over the hip-joint.
180.
Female.
52.
Flexion painful ; tenderness on
pressure over the sacrum.
181.
Male.
46.
No notes.
182.
Female.
57.
Began fifteen years ago ; pain in
outside of leg.
183.
Female.
51.
Lame.
184.
Female.
46.
Began five years ago. Pelvic
thickening ; distinct pain on pres-
sure over the hip-joint.
185.
Female.
46.
Began sixteen years ago. No
tenderness on pressure over hip-
joint, nor wasting of glutei.
186.
Male.
60.
No notes.
187.
Female.
62.
Been two months ill ; has had
rheumatic gout. Some wasting of
glutei ; sudden onset. Both legs
affected.
188.
Female.
50.
Gout in the family ; slight case.
189.
Female.
43-
Has had acute gout. Heberden's
nodes ; swelling.
190.
Male.
59-
Rheumatic affection of eyes ; has
had lumbago attacking left sacro-
iliac joint. Tenderness and wast-
ing of leg.
IQI.
—
—
No notes.
192. Male. 58.
Has had lumbago and eczema.
Both sides affected.
io8 SCIATICA : A FRESH STUDY
No
Sex.
Age.
193-
Female.
53-
Gout in hand ; has had lumbago.
194.
Female.
72.
Suffered from rheumatism.
195.
Female.
45.
Rheumatism in knee.
196.
Male.
55.
Said to be cured by electricity.
197.
Male,
72.
Very marked tenderness on pres-
sure over the hip-joint.
198.
Female.
50.
Both knees and hips affected ; has
had lumbago.
199.
Male.
55.
Left shoulder troublesome ; has
had lumbago.
200.
Male.
33.
Sacro-iliac joint affected ; relieved
by walking.
201.
Male.
35.
No notes.
202.
Male.
70.
Cannot stretch himself out ; very
decided tenderness on pressure over
the hip-joint.
203.
Male.
52.
Tension and fulness at the hip-
joint.
204.
Male.
49-
Considerable w^asting of glutei ;
tenderness on pressure over the
hip-joint.
205.
Male.
60.
Some pelvic swelling.
206.
Female.
54.
Shoulder affected by rheumatism.
207.
Female.
60.
Limitation of circumduction at
hip-joint ; obliteration of folds of
nates ; tenderness on pressure over
the trochanter.
208.
Female.
43-
"Cruel pain."
209.
Female.
55.
Lame.
210.
Male.
52.
Tenderness on pressure over the
hip-joint.
APPENDIX II
109
No.
Sex.
Age.
211.
Male.
47.
212.
Female.
42.
213.
Male.
65.
214.
Female.
55.
215.
Male.
50.
216.
Female.
51.
217.
Female.
52.
218.
Male.
35.
219.
Female.
50.
220.
Female.
40.
221.
Male.
36.
222.
Male.
56.
223.
Female.
60.
224.
Male.
50.
on pressure over
225. Male. 50.
226.
227.
Male.
Female.
50.
45.
No tenderness
the hip-joint.
No notes.
No notes.
Muscular rheumatism ; sudden
difficulty in walking.
Tenderness on pressure over the
hip-joint.
Tenderness on pressure over the
hip-joint.
Wasting of glutei.
Circumduction perfect ; some ten-
derness on pressure over the hip-
joint.
Rheumatism in right arm ; tender-
ness on pressure over hip-joint.
Rheumatism in knees ; has had
lumbago.
Not worse after walking.
Old case. Chronic lumbago ;
nervous ; limb starts.
Three years ill ; pain very acute.
Wasting of glutei, and some obliter-
ation of folds of nates ; decided
tenderness on pressure over the
hip-joint.
Wasting of glutei, and obliteration
of folds of nates ; tenderness on
pressure over the hip-joint.
Slight case.
Slight case.
no SCIATICA: A FRESH STUDY
No.
228,
Sex. Age.
Female. 70.
229. Male. 58.
230.
—
—
231.
Male.
45.
232.
Male.
43-
233-
Female.
54.
234.
Male.
50,
235.
Female,
40.
236.
Female.
43.
237.
Female.
72.
238. Female. 41
239. Male. 35.
240. Female. 64.
no
the
the
of
Senile. Some tenderness on pres-
sure over the hip-joint.
Wasting of glutei well marked ;
no tenderness on pressure over the
hip-joint.
No notes.
Decided wasting of glutei, and
obliteration of folds of nates ;
tenderness on pressure over
hip-joint.
Tenderness on pressure over
hip-joint.
Shoulder affected ; wasting
glutei ; ankle swollen.
Considerable tenderness on pres-
sure over the hip-joint.
Wasting of glutei; doubtful tender-
ness on pressure over the hip-joint.
Slight case.
Both legs affected ; has had lum-
bago ; decided tenderness over both
hip-joints.
Three years ill. Shoulder affected ;
internal rotation at hip-joint in-
complete.
Shoulders ache ; some difficulty in
circumduction at hip-joint ; cannot
stand upright ; wasting of glutei ;
tenderness on pressure over capsule.
Some limitation of power of cir-
cumduction ; tenderness on pres-
sure over the sciatic nerves on
both sides.
APPENDIX II
I II
No.
241.
243-
244.
250.
251.
252.
Sex.
Female.
Male.
Male.
Male.
Male.
Age.
50.
242. Female. 27.
60.
55.
245.
—
—
246,
Female.
61.
247.
Female.
50.
248. Female. 71,
249. Male. 47,
69.
68.
Has had lumbago ; limitation of
powers of circumduction at hip-
joint ; throbbing pain when she
walks.
A teacher. Both legs affected ;
had tenderness on pressure over
hip-joint, now gone.
Pain in peroneal region of leg.
Result of an accident. Distinct
obliteration of folds of nates ; some
tenderness on pressure over the
hip-joints.
No notes.
History of old sciatica.
Fifteen years bad. Neck cracks
on movement ; cannot lie on the
affected side ; some tenderness on
pressure over the hip-joint.
Has had lumbago. Difficulty when
lying down in turning ; cannot
cross bad leg over its neigh-
bour.
Sudden attack. Hanging affected
limb causes pain, as does lying on
affected side ; cannot put on stock-
ing ; easiest when leg extended.
No notes.
Tired by walking ; decided wast-
ing of glutei, as also tenderness on
pressure over the hip-joint.
Attack eight years ago, well now.
112 SCIATICA: A FRESH STUDY
No. Sex.
253. Male.
254. —
255. Male.
256. Male.
Age.
51.
69.
69.
257.
Female.
49,
258.
Female.
30-
259.
Female.
35.
260.
Female.
55-
261.
Female.
50,
262.
Male.
35.
263.
Female.
63.
Has had lumbago. Some wasting
of glutei ; fulness and heat felt
over the hip-joint, and excessive
tenderness on pressure ; some sac-
ro-iliac tenderness also on pressure.
Both legs affected ; difficulty and
pain when lying down, on turn-
ing the body ; decided wasting of
glutei, and some tenderness on
pressure over the hip-joint.
Some numbness and giddiness.
Slight case.
On right side slightly, also on left ;
marked wasting of glutei ; some
tenderness on pressure over the
hip-joint.
Gout and eczema ; never had
lumbago. Slight case.
Began a month ago ; shoulders
very rheumatic. Slight case.
Sacro-iliac tenderness on pressure ;
considerable tenderness on pressure
over the hip-joint.
Right shoulder troublesome; ten-
derness on pressure over hip-joint ;
exertion hurts, and causes pain in
front of tibia.
Has had rheumatism in knee.
Ill for a year. Trouble in shoulder ;
" gout on nerves."
Swelling of finger-joints ; marked
tenderness ; winces on pressure
over hip-joint.
APPENDIX II
113
No, Sex.
264. Male.
265. Female.
266. Male.
268. Male.
269. Female.
270. Male.
271. Female.
272. Male.
273. Female.
Age.
61.
35.
59.
267. Male. 23.
60.
65.
59.
55.
70.
42.
Hip-joint, no tenderness on pres-
sure in that region ; obliteration
of folds of nates.
Gouty swelling above ankle ; ten-
derness on pressure over the hip-
joint.
No general rheumatism ; marked
wasting of glutei ; tenderness on
pressure in front of capsule of
hip-joint.
Three months ill. Has had lum-
bago, he says, from sprain ; been
three weeks in bed.
Knee and foot both swollen ; knee
gives him most trouble.
Ill fifteen years ago ; has now gout
in fingers and toe-joints.
Excessive tenderness on pressure
over the capsule of hip-joint.
Ill two years ago. Subject to
gouty pains. As a result of
stretching nerve, loss of power to
lift her leg.
Old case. Been troubled with
eczema ; has had lumbago.
Brothers and sisters rheumatic gout.
Difficulty when lying down in
turning her body ; internal rota-
tion at hip-joint affected ; con-
siderable wasting of glutei 5 trouble
began in her back ; some tender-
ness on pressure over the capsule
of joint.
8
114
SCIATICA
No.
274.
Sex. Age.
Male. 40.
275.
Male. 60.
276.
Female.
30.
277.
Male.
78.
278.
Male.
62.
279.
Male.
52.
280.
Male.
70.
281.
Male.
50.
282.
Female.
60.
283.
Female.
66.
A FRESH STUDY
Has had sciatica twice, now free
from pain ; acute gout in toe and
knee.
Father's family had gout ; has had
lumbago. Wasting of glutei, but
not great ; difficulty in internal
rotation of hip-joint ; marked ten-
derness on pressure over the cap-
sule ; suspicious pelvic thickening.
Has had lumbago ; much tender-
ness present on pressure over the
hip-joint.
Gouty knobs on fingers. Slight
case.
Rheumatism in shoulder ; has not
had lumbago ; no limitation of
circumduction, but difficulty in
taking off boots ; great wasting of
glutei, and excessive tenderness on
pressure over the hip-joint.
Circumduction at hip-joint affected ;
great wasting of glutei ; distinct
fulness, and marked tenderness on
pressure over the capsule of joint.
Has had lumbago ; very decided
wasting of glutei ; also some wast-
ing of the muscles of the thigh.
A weak old man.
No notes.
Relapse after five years ; slight
case.
Wasting of the glutei ; swelling ^
pelvic deposit.
APPENDIX II
115
No.
284.
Sex.
Female.
Age,
80.
2&5.
Female.
70.
286.
Female.
50.
287.
288,
Male. 68.
289.
Female.
46,
290.
Female.
50.
291.
Male.
45-
292. Female. 73.
293. Female.
Ill for someyears ; both legs affected,
right ankylosed ; very decided
wasting of glutei and thigh ; pelvic
deposit.
Twelve months lame ; free from
pain when lying down ; pain in
going down stairs.
Well-marked case of gout in her
hip-joint ; almost every joint in
her body affected ; very marked
tenderness on pressure over the
hip-joint.
Result of an accident ; much better.
Gamekeeper. Gouty knees and
marked pain on internal rotation
at hip-joint ; very decided tender-
ness on pressure over the capsule,
which seems distended.
Arm affected ; no limitation of
circumduction. When bad, can-
not put a foot under her.
Knees very rheumatic ; tenderness
on pressure over the hip-joint.
Flexion very imperfect ; pain on
external rotation at the hip-joint ;
much wasting of glutei ; distinct
fulness at, and great tenderness
on pressure over the capsule.
Some trouble in external and in-
ternal rotation at hip-joint ; muscles
very tense in front of the capsule.
Difference of opinion as to the
exact nature of the illness.
Lameness after walking.
ii6 SCIATICA: A FRESH STUDY
No. Sex.
294. Male.
Age.
295. Female. 49.
296. Female. 41,
297. Male. 56.
298. Male. 46.
299. Male.
300. Male.
56.
70.
Gouty myalgia from cold ; pain in
external rotation at the hip-joint ;
wasting of glutei ; some tender-
ness on pressure over the capsule.
Rheumatic gout in feet. Numb-
ness in arms ; rheumatism in hip-
joint ; some wasting of glutei, and
distinct tenderness on pressure over
the capsule.
Rheumatism in arms and leg ;
mother rheumatic. Some difficulty
of external rotation at the hip-
joint ; wasting of glutei, and some
obliteration of folds of nates. Feels
as if she would like to have her leg
pulled out.
Three weeks ill. Gout in other
joints ; flexion imperfect, more on
one side than the other, at hip-
joint ; external rotation impos-
sible ; a little pelvic thickening
on right side. Cannot get on
horseback. Both limbs affected.
Swelling of toe-joints. Flexion
imperfect at hip-joint ; marked
tenderness over front of capsule.
Massage did no good — distinctly
aggravated the pain.
Some difficulty in rotating the hip-
joint outwards.
Gout in left foot and rheumatism in
knees. Much obliteration of folds
of nates ; no tenderness on pressure
over the hip-joint ; some pain on
thigh and calf of leg after exertion.
APPENDIX II
117
No. Sex.
301. Male.
Age.
62.
302. Male. 60.
303, Female.
304. Male.
306. Male.
307. Female.
308. Female.
52.
56.
305. Male. 55.
50.
No gout or rheumatism ; never
had lumbago. Decided oblitera-
tion of folds of nates ; some tender-
ness on pressure over the hip-joint.
Both joints ; right flexion and inter-
nal rotation at hip-joint imperfect.
Left flexion and internal rotation
affected ; great wasting of glutei ;
considerable tenderness on pressure
over the capsule.
Eight years bad. Heberden's
nodes ; deficiency in internal rota-
tion at hip-joint.
Nearly three years ill ; no gout or
rheumatism. External rotation at
hip-joint decidedly affected ; no
wasting of glutei or tenderness on
pressure over capsule ; must lift
right foot over left if sitting long.
Wasting of glutei ; decided
obliteration of folds of nates ; con-
siderable tenderness on pressure
over the hip-joint.
Flexion at hip-joint not complete.
Shoulders rheumatic. Internal
rotation at hip-joint much affected ;
troubled in standing erect.
Double case. Flexion on right
somewhat affected, external rota-
tion more so at hip-joint ; tender-
ness on pressure over the capsule
decided. Flexion of left nearly
perfect ; considerable tenderness on
pressure over capsule on that side.
ii8 SCIATICA: A FRESH STUDY
No.
309-
311-
312.
Sex.
Male.
Age.
69. Ill for two years ; some gout and
rheumatism. Mother rheumatic ;
father no rheumatism.
310. Male. 35.
Wasting of glutei ; evident tender-
ness on pressure over the hip-joint.
Great difficulty in w^alking at first.
— — Old case.
Female. 64.
313. Male.
314. Male.
56.
75.
315. Female. 31,
316. Male. 61,
317. Male. 34.
Rheumatic gout ; mother gouty.
Occasional attacks.
First attack.
Circumduction affected both on
right and left sides at the hip-
joints ; some wasting of glutei on
left ; no tenderness on pressure
over the capsule on either side ;
cannot lift the one leg over the
other.
Ill for three years ; grandfather on
both sides gouty ; no history of
lumbago. On her back for some
months ; had to lift the one leg
over the other with her hands.
Gouty for some years ; has had
lumbago. Flexion unaffected ;
internal rotation somewhat, and
external rotation decidedly, im-
paired at hip -joint ; much
tenderness on pressure over the
capsule.
Six months ill. Clear wasting of
glutei, and decided tenderness on
pressure over the hip-joint.
APPENDIX II
119
No. Sex. Age.
318. Male. 60.
319. Male. 42.
320. Male. 34.
321. Male. 62.
322. Female. 55.
323. Female. 44.
324. Male. 55.
History of gout and rheumatism.
Some wasting of glutei, and also
some obliteration of folds of nates ;
a little tenderness on pressure over
the hip-joint. Suffers great pain.
Grandfather gouty ; mother rheu-
matic gout. Both legs affected;
now quite recovered.
Arms troubled ; some tenderness
over the lumbo-sacral articulation ;
very decided tenderness on pres-
sure over the hip-joint.
Nails brittle ; has had lumbago.
Flexion in both hip-joints im-
perfect, more so in the right ; some
wasting of glutei ; decided oblitera-
tion of folds of nates ; undoubted
tenderness on pressure over the
capsule, but doubtful fulness. Im-
proved much.
Rheumatism in legs and arms.
Internal and external rotation con-
siderably impaired at the hip-joint ;
wasting of glutei and obliteration
of folds ; great tenderness on pres-
sure over the capsule.
Rheumatism in legs and arms.
Some difficulty of internal rotation
of hip-joint ; decided tenderness
on pressure over the capsule.
Rather gouty. Neither internal
or external rotation of hip-joint 5
glutei free ; distinct wasting of
glutei folds ; no obliteration ; some
120 SCIATICA: A FRESH STUDY
No.
Sex.
Age
325. Female. 59.
326. Female. 40.
328.
330.
331-
Female.
Female.
Male.
Female.
55.
66.
329. Male. 67.
63.
332. Male. 53.
333. Female. 65.
tenderness on pressure over the
capsule ; fixed pain in buttock.
Could not put his heel down.
Toes and knees bad ; has not had
lumbago. Some tenderness on
pressure over hip-joint.
Distinct tenderness on pressure
over the hip-joint.
No notes.
Some difficulty, and more in in-
ternal rotation of hip-joint ; dis-
tinct wasting of glutei and oblitera-
tion of folds of nates, as also
tenderness \n pressure over the
hip-joint.
Impaired power of internal rota-
tion in hip -joint, with some
tenderness on pressure over the
capsule.
Gout in toe. Tenderness on pres-
sure over the head of the rectus.
Four months ill at this time ; bad
five years ago. Doubtful wasting
of glutei ; distinct tenderness on
pressure over the hip-joint.
Internal rotation decidedly affected
at hip -joint; clear wasting of
glutei and obliteration of the folds
of nates, with decided tenderness
on pressure over the capsule.
Slight wasting of glutei and
obliteration of folds of nates. Told
she was suffering from neuritis.
APPENDIX II
121
No. Sex.
334. Female.
335. Male.
Age.
64.
47-
336. Male.
37'
337. Male. 55.
338. Female. 51.
339. Male. 67,
No notes.
Pain on forcible extension, and
great difficulty in internal rotation
of hip-joint ; some wasting of
glutei, and obliteration of folds
of nates ; distinct tenderness on
pressure over the capsule ; left
Strathpeffer much better.
Three months ill. No rheuma-
tism ; some wasting of glutei, and
obliteration of folds of nates ; rest-
less when first goes to bed ; left
Strathpeffer improved.
Both legs affected ; has had lum-
bago ; left limb some trouble in
flexion, none on the right ; ex-
ternal rotation very deficient on
left, less so on right at the hip-
joint; marked wasting of glutei
on left side, much less on right ;
folds of the nates much obliterated,
with very marked tenderness on
pressure over both capsules; gets
into upright position very stiffly.
Fourteen weeks ill. Decided diffi-
culty in flexion ; also of internal
and external rotation of the hip-
joint ; slight wasting of glutei ;
marked tenderness on pressure over
the capsule ; left Strathpeffer im-
proved.
Sudden attack four years ago, slight
seizure. Rheumatism in knees ;
has had lumbago, and some diffi-
culty in complete flexion, and
122 SCIATICA: A FRESH STUDY
No. Sex.
Agi
340. Male. 72.
341. Female. 62,
342. Female.
343. Male.
72.
344-
t emale.
50
345.
Female.
47-
346.
Female.
70,
more of internal and external rota-
tion (which causes pain) on hip-
joint ; wasting of muscles of leg ;
no tenderness on pressure, but
undoubted pelvic deposits.
Ten months ailing. Has had
lumbago ; decided tenderness on
pressure over the hip-joint ; had
hip-joint disease when fifteen years
of age.
Long ill. Some difficulty in
flexion, more of external rotation ;
marked tenderness on pressure over
the hip-joint; cannot move her
leg at night.
Mild case ; did well. Rheumatic
pains.
Pain in elbow and right knee ;
external rotation affected, internal
much more so at hip -joint ; some
wasting of glutei, and obliteration
of folds of nates ; some swelling of
hip affected, and pain when lying
down.
Shoulders, knuckles, and big toe
painful ; tenderness on pressure
over both hip-joints ; difficulty in
getting into bed ; both legs affected.
Began a year ago ; has had lumbago.
Off and on twenty years bad ;
toe-joint been inflamed ; flexion
imperfect ; no external rotation
possible ; internal rotation incom-
plete at hip-joint ; some wasting
APPENDIX II 123
No. Sex. Age.
of glutei ; distinct obliteration of
folds of nates ; decided tenderness
over capsule ; some pelvic deposits.
Improved by treatment.
347. Male. 30. Five months ill. Some wasting of
glutei, and distinct partial obliter-
ation of folds of nates, as also
tenderness on pressure over the
hip-joint ; pain when standing up,
and when he lies on the affected
side.
348. Male. 56. Has had lumbago ; external rota-
tion at hip-joint incomplete ; some
wasting of glutei, and decided
tenderness on pressure over the
front of the hip-joint.
349. Female. 50. Ill for years. Has had lumbago ;
some tenderness on pressure over
the hip-joint. Slight case ; quite
well in a day or two.
350. Male. 59. Seven weeks in bed. Has had
lumbago ; nothing imperfect in
circumduction at hip-joint ; some
wasting of glutei ; decided tender-
ness on pressure over the hip-joint.
351. Male. 60. Bad two years ago. Rheumatism
in arm, small toes swollen, has had
lumbago ; some difficulty in com-
plete flexion and internal rotation
of hip-joint ; doubtful wasting of
glutei, and distinct tenderness on
pressure over the hip-joints. Both
legs affected. Improved with spa
treatment.
124 SCIATICA: A FRESH STUDY
No. Sex. Age.
352. Female. 60. Leg wasted ; lame.
353. Female. 33. Knee-joint hot and swollen ; leg
wasted ; quite lame ; both hip-
joints affected.
354. Male. 62. Rheumatism in ankles and knees ;
has had slight lumbago ; full flexion
imperfect ; tenderness on pressure
over right hip-joint, none over
left ; numbness down his legs.
Improved with spa treatment.
Double case.
355. Male. 75. Hands slightly gouty, knees much
affected ; external rotation at hip-
joint distinctly interfered with ;
much wasting of glutei ; no ten-
derness on pressure over the capsule.
Cured case.
356. Male. 53. Ill three months ago. Shoulder
bad. Left Strathpeffer much im-
proved.
357. Male. 44. Four weeks ill. Has had lumbago
occasionally for twelve years back ;
distinct wasting of glutei, as also
considerable obliteration of folds
of nates; decided tenderness on
pressure over the hip-joint ; no
fulness of capsule ; difficulty in
tying shoe-laces.
358. Male. 65. Shoulders rheumatic ; ankylosis in
both hip-joints.
359. Male. 61. Hereditary rheumatism ; has had
lumbago. Left leg flexed and
everted from injury ; cannot lie
on the affected side.
APPENDIX II 125
No. Sex. Age.
360. Male. 48. Keeper ; three months ill ; could
not move in bed for two weeks.
Wasting of glutei, and considerable
obliteration of folds of nates, with
marked tenderness on pressure over
the hip-joint.
361. Female. 54. Hand, arm, and toe -joints all
affected by rheumatism ; no im-
pairment of circumduction at hip-
joint — never actually lame, came
on suddenly, like toothache.
362. Male. 48. Gout in shoulders ; has had lum-
bago ; distinct tenderness on pres-
sure over the hip -joint. Left
improved by spa treatment.
363. Male. 60. Hip -joint completely ankylosed
with pelvic deposit.
364. Male. 76, Interference with full internal and
external rotation of the hip-joint ;
decided tenderness on pressure over
the capsule.
365. Male. 60. Twelve months ill ; has had lum-
bago. Full external rotation
hampered, and painful at the hip-
joint ; some wasting of glutei, and
considerable obliteration of folds
of nates ; decided tenderness on
pressure over the capsule.
366. Male. 50. Has had lumbago ; distinct de-
ficiency in full internal rotation
of the hip-joint ; decided wasting
of glutei, also obliteration of the
folds of nates ; great tenderness on
pressure over the capsule ; pain
comes and goes quickly.
126 SCIATICA: A FRESH STUDY
No. Sex. Age.
367. Female. 50.
368. Female. 52.
369. Male. 61.
370. Male. 60.
371. Female. 50.
372. Female. 42.
373. Female. 56.
374. Female. 65.
375. Male. 42.
Long duration. Deficiency in
full external rotation at hip-joint ;
wasting of glutei ; distinct tender-
ness on pressure over the capsule.
Slight case ; cured by rest.
Began slowly ; some pain in groin ;
twinge, nearly fainted ; has had
lumbago, said to be rheumatism, in
right hip.
No gout or lumbago ; pain in ball
of heel ; lameness for a week after
golfing.
Rheumatism in both arms ; full
flexion, and internal rotation at
hip-joint decidedly aflFected ; wast-
ing of glutei, folds of nates not so
distinct ; very great tenderness on
pressure over the capsule ; left
Strathpeffer better.
Full external rotation at hip-joint
much restricted ; very great tender-
ness on pressure over the hip-joint.
No notes.
Slight pain on flexion, no interfer-
ence otherwise with circumduction
at hip-joint ; some wasting of
glutei and distinct partial oblitera-
tion of folds of nates ; no tender-
ness on pressure over the capsule.
Interesting case ; getting well be-
fore beginning spa treatment.
Carpenter. Some limitation of
full external rotation at hip-joint ;
decided wasting of glutei on the
right side, less on left ; marked
APPENDIX II
127
No. Sex.
Age.
376. Male. 50,
377. Male. 45.
378. Male. 62.
379. Female. 50.
380. Female. 65.
tenderness on pressure over cap-
sule, both sides, more on right than
left. Long helpless ; double case.
Full flexion much affected ; very
marked tenderness on pressure at
hip-joint over capsule. Improved
by spa treatment, but still great
tenderness of hip-joint persisted.
Three v^^eeks ill. Full flexion and
internal rotation, but some trouble
in external rotation at the hip-
joint ; decided wasting of glutei
and much obliteration of folds of
nates ; decided tenderness on pres-
sure over the capsule. Improved
by spa treatment.
First attack ; been two months
bad ; shoulders long ago rheu-
matic. Some wasting of glutei
and obliteration of folds of nates ;
tenderness on right, none on left
side in hip-joints. Began suddenly
on lifting a cask ; difficulty in
turning in bed and putting one
foot before another.
No interference with circumduc-
tion of hip-joint ; decided tender-
ness on pressure over capsule. Im-
proved by spa treatment.
Rheumatism in head, throat, and
back. Full flexion difficult in
both hip-joints ; much obliteration
of folds of nates ; some tenderness
over the capsule. Back trouble-
some ; slight case.
128 SCIATICA: A FRESH STUDY
No.
381.
Sex.
Female.
Age.
56.
382. Male. 60.
383.
384.
Female.
Female.
65.
64.
385. Male. 45.
86. Male.
56.
Has had lumbago. Full flexion at
hip-joint impossible ; external and
internal rotation unaffected ; con-
siderable wasting of glutei, as also
obliteration of folds of nates ;
decided tenderness on pressure over
the capsule. Has to help her leg
up in getting into a carriage.
Circumduction at hip-joint not
affected ; decided wasting of glutei,
as also obliteration of folds of
nates ; distinct tenderness on pres-
sure over the capsule.
Sister gouty. Pain on taking a
high step ; some pelvic thicken-
ing ; pains in back of leg.
Has had slight lumbago. Full
flexion, external and internal rota-
tion at hip-joints much affected ;
doubtful wasting of glutei ; very
distinct tenderness over the capsule.
Cannot put right foot over the left.
Five months since attacked ; six
weeks in bed ; previous seizure ten
years ago. Full flexion and ex-
ternal rotation much affected, but
internal rotation complete at hip-
joint ; no evident wasting of glutei
or obliteration of folds of nates ;
tenderness on pressure over the
capsule very decided. Cannot put
right leg over the left.
Rheumatism in arms and legs ; has
had lumbago six or seven times.
Slight stiffness in circumduction at
hip-joint.
APPENDIX II
129
No.
Sex.
Age
3^7^
Female.
60.
388.
Female.
62.
389. Female. 32.
390. Female, 66.
391. Male. 60.
392. Male.
393.
40.
Female. 60.
No notes.
Left shoulder rheumatic. Heber-
den's nodes ; knuckles thickened ;
full flexion and internal rotation at
hip-joint much affected, not so ex-
ternal rotation ; wasting of glutei
and obliteration of folds of nates j
decided tenderness on pressure over
the capsule. Complains only of
knee.
Complains of shoulder and suffers
from pleurodynia. Only tender
on pressure over the hip-joint.
Gout in toe-joint ; some pain and
resistance in circumduction at the
hip-joint.
Six years bad ; suffers from rheu-
matism ; pain in shoulder and fore-
arm ; never had lumbago. Decided
impairment of rotation, internal
and external, at hip-joint ; some
wasting of glutei and obliteration
of folds of nates ; very decided
tenderness on pressure over capsule.
Rheumatism in arms. Some wast-
ing of glutei and obliteration of
folds of nates, and distinct tender-
ness on pressure over the hip-joint.
A slight case, cured by spa treat-
ment.
Has had lumbago. At the hip-
joint circumduction complete ;
tenderness over both capsules ;
quite decided double case.
9
I30 SCIATICA: A FRESH STUDY
No. Sex. Age.
394. Male. 66. Two months ill. Heberden's nodes
in two or three fingers ; at hip-
joint circumduction unaffected ;
folds of nates somewhat obliterated.
Mild case ; getting better.
395. Male. 69. Uric acid gravel ; knees, rheu-
matic gout. Full flexion slightly
affected ; external and internal
rotation at hip -joint consider-
ably affected ; much wasting of
glutei ; folds of nates obliterated
to a certain extent ; doubtful
tenderness on pressure over cap-
sule. Left Strathpeffer, having lost
his limp, and much improved.
396. Male. 69. Heberden's nodes ; full extension
hurts, otherwise circumduction at
hip-joints unaffected. Very decided
tenderness on pressure over cap-
sule.
397. Male. 63. Been ill for a year ; father rheu-
matic. Right side, full flexion
decidedly affected, internal and
external flexion much more so ;
left flexion same as right, but in-
ternal and external rotation alto-
gether incomplete. No tenderness
on pressure over capsule. Im-
proved by spa treatment.
398. Female. 67. Circumduction unaffected ; some
wasting of glutei ; decided tender-
ness on pressure over the hip-
joint.
399. Female. 30. Has had lumbago.
APPENDIX II
131
No. Sex.
400. Female.
Age.
80. Decided affection of internal rota-
tion at hip-joint ; flexion and ex-
ternal rotation normal ; doubtful
case.
402. Female.
403. Female.
60.
52.
401. Male. 53. Acute attack for three days ;
previous seizures twelve and six
years ago ; never had lumbago.
Full internal rotation at hip-joint
brings on pain ; some wasting of
glutei and obliteration of folds of
nates. Distinct tenderness on pres-
sure over the capsule. -
Sacro-iliac pains ; lame.
Very sudden seizure ; all move-
ments of limb affected at hip-joint ;
internal rotation decidedly affected,
also external ; doubtful tenderness
on pressure over trochanter on left
leg.
No objective sign of any kind.
Knees rheumatic ; mother rheu-
matic. Full circumduction at hip-
joint complete ; decided tenderness
on pressure over the capsule.
Twenty-five years bad ; could not
lift the affected leg over its neigh-
bour. At hip-joint flexion distinctly
affected ; external rotation imper-
ceptible ; internal rotation decidedly
affected. Pain inside the knee-
joint.
Extension painful ; flexion not
affected at hip-joint ; pain on walk-
ing, and yet worse when in bed.
404. Female.
405. Male.
62.
53'
406. Female. 46.
407. Male. 58.
132
SCIATICA: A FRESH STUDY
No.
408.
Sex.
Female.
Age.
72.
409. Female. 50.
410.
Female.
71.
411.
Male.
75.
412.
Female.
46.
413.
Male.
55.
414.
Female.
415.
Male.
50.
416. Female. 40.
417. Female. 50.
At hip -joint flexion distinctly
affected ; internal rotation im-
paired ; in bed for five or six
days. Left Strathpeffer cured.
At hip-joint full flexion incom-
plete; rotation more so. Has to
lie on the affected side to keep
hot when in bed.
Improved by spa treatment.
Slight case.
Also slight case.
Heberden's nodes ; has had lum.-
bago. Frequent attacks ; great
pain at night. Cured.
Stiffness ; slight case.
Eighteen months ill ; laid up for
eight weeks in bed. At the hip-
joint circumduction perfect ; exces-
sive tenderness over capsule, both
in front and behind. Has to get
up at night for relief from pain,
but does so with difficulty, and
cannot tie his bootlaces.
Months bad ; rheumatism in left
leg and shoulder. At hip-joint
full flexion decidedly incomplete ;
internal rotation more so ; external
rotation also much impaired ; some
tenderness on pressure over cap-
sule, and causes pain down the leg.
Six weeks ill, five weeks in bed;
rheumatism fifteen years ago. Has
pain both on external and internal
rotation of hip-joint.
APPENDIX II 133
No. Sex. Age.
418. Male. 48. Bad fourteen years ago; three
months ill, three weeks in bed ;
could not turn himself. At hip-
joint circumduction incomplete ;
extension affected ; no tenderness
over course of sciatic nerve ; over
capsule exceedingly severe pain.
Rest relieves. Double case.
419. Male, 52. Sciatica lasted more than a year ;
rheumatism in shoulder. Attack
ten years ago ; lumbago over a year.
At hip-joint circumduction com-
plete, unless when leg extended
and not bent at the knee; much
pain on pressure over the capsule.
Trouble began in haunch, and
spread down the back of the leg ;
most pain in that region when he
walks. Ill for six or seven years ;
pain in hip when he sneezed.
Double case. Cured.
420. Male. 4 1 . Rheumatism in left hand and ankle ;
never had lumbago. At hip-joint,
on right side, full flexion imperfect ;
pain on extension ; great tender-
ness on pressure over left capsule,
much less on right ; lame when
attack comes on. Double case.
421. Female. 71. Rheumatism in back and knees;
fingers ; frequent attacks of lum-
bago; at hip-joints right, full flexion
markedly deficient, left, complete ;
right internal rotation somewhat
affected, but left normal; internal
rotation right, left not at all ;
134 SCIATICA: A FRESH STUDY
No.
Sex.
Age.
422. Female. 60.
423. Female. 46.
424. Female. 66,
425. Male. 60.
tenderness on pressure over cap-
sule — right decided, left doubtful.
Went off cured, except a little
pain in the left leg.
A little gout in one finger, and
rheumatic pains in shoulder; some
want of normal motion in hip-
joint when flexed, otherwise all
right ; decided tenderness on pres-
sure over capsule. Pain never
lower than knee.
Shoulders and big toe gouty ; been
nine weeks ill, and two weeks in
bed ; pain and difficulty in full
flexion at hip-joint ; some difficulty
also in internal and external rota-
tion. Pain came on all at once
on the outside of the hip, and after-
wards on outside of leg. Sneezing
aggravated the pain. Left Strath-
peffer almost well.
Rheumatism in shoulders and arms.
Six years bad ; worse for the last
two years. At hip-joint flexion
complete ; internal rotation very
incomplete, external rotation less
so ; decided wasting of glutei, and
obliteration of folds of nates.
Three or four years bad. At hip-
joint flexion complete ; internal
rotation very deficient ; great wast-
ing of glutei ; no tenderness on
pressure over the capsule ; cannot
put one foot behind the other.
Evident pelvic deposits; so-called
rheumatoid arthritis of hip.
APPENDIX II 135
No. Sex. Age.
426. Male. 53. Twenty or thirty years since the
trouble began first ; bad for twenty
days at this time. Slight obliter-
ation of folds of nates, and a little
tenderness on pressure over the
hip-joint. Scarcely any lameness.
427. Female, 50. Began a year ago ; hips of both
legs bad ; could not bear them to
be touched. Relieved by morphia.
Slight case,
428. Male. 70. Catarrh of throat and eczema ;
slight tenderness on pressure over
hip-joint.
429. Male. 72. Bad two months. Rheumatism
in knee for four years ; difficulty
in turning in bed ; when he stoops
cannot straighten himself up ; pain
up and down the thigh, reaching
to the foot.
430. Male. 41. Rheumatism in foot for twelve
years, and attacks of lumbago ; at
hip-joint flexion on right side de-
cidedly impaired, left not quite so
much so ; right internal rotation
much limited, left less hampered ;
right external rotation impaired,
left about the same or less ; decided
wasting of glutei, and obliteration
of folds of nates on left, more on
right ; very distinct tenderness on
pressure over the capsule on right ;
some on left, and threatening anky-
losis — might be called rheumatoid
arthritis of right hip. Double case.
431. Male. 58. Mild case.
136 SCIATICA: A FRESH STUDY
No. Sex.
432. Male.
Age.
60.
on right
433. Female. 40.
At hip-joint full flexion
diminished by nearly one-half, on
left not so marked ; external rota-
tion, right, markedly impaired,
left much less so ; wasting of right
glutei ; tenderness on pressure over
capsule — same in both ; " neu-
ralgia " feet and hips ; want of
feeling when bad ; fainted with the
pain in the left leg. Double case.
Varicose veins ; some impairment
at the hip-joint of full flexion ;
internal and external rotation ;
swelling and heat of the capsule,
and great tenderness on pressure
over it.
Rheumatism in both hands ; at
hip-joint distinct limitation of full
flexion, with very sharp pain. Left
rather the better for spa treatment.
Circumduction at right hip com-
plete ; internal rotation of left leg
impaired ; extension also affected ;
tenderness on pressure over both
joints distinctly marked. Sudden
attack ; limp. Double case.
Knee troubled; began a fortnight
ago ; wasting of glutei, and som.e
obliteration of folds of nates.
Doubtful case.
437. Female. 51. Knee rheumatic ; at hip-joint clear
impairment of full flexion, and
slight of external rotation ; marked
tenderness on pressure over the
capsule.
434. Female. 60.
435. Male. 61.
436. Male. 60.
APPENDIX II 137
No. Sex. Age,
438. Male. 61. Has had phlebitis and acute pain
in shoulder ; bad for six or seven
weeks ; in bed for four weeks.
Circumduction complete at hip-
joint, left leg ; wasting of glutei ;
tenderness on pressure over capsule
quite decided, both over right and
left ; pains all about hips at first.
Limps a good deal, and difficulty
in crossing legs — worst at night.
Left Strathpeffer cured.
439. Female. 46. Two weeks ill. Pain in back and
loins ; limps a good deal.
440. Male. 67. Two months bad. Hereditary
rheumatism ; pain in right shoulder ;
foot swells ; circumduction com-
plete at hip-joint ; some wasting
of glutei. Left improved by spa
treatment.
441. Male. 66^ At hip-joint full flexion and ex-
ternal rotation affected ; distinct
tenderness on pressure over the
capsule ; pelvic deposit.
442. Male. 27. Family scrofulous. At hip-joint
circumduction hampered ; marked
tenderness on pressure behind, also
in groin, but not so severe.
443. Male. 39. Attack of acute gout ; occasionally
lumbago ; extension causes a little
jag. History of local violence and
cold.
444. Male. 49. Attack nineteen years ago ; has
had lumbago.
445. Male. 57. Stiffness in joints, especially of leg ;
has had lumbago. Slight case.
138 SCIATICA: A FRESH STUDY
No. Sex.
446. Female.
Age.
69.
447. Female. 39.
448. Male. 30.
449. Female. 44.
450. Male. 35,
451. Female.
Inherits gout ; sciatica in left leg.
Right leg fractured eight years ago.
At hip-joint some limitation of
full flexion, more so of external
and internal rotation ; distinct
wasting of glutei ; very decided
tenderness on pressure over cap-
sule. A housemaid ; severe case.
Left StrathpefFer cured.
At hip-joint circumduction com-
plete ; distinct wasting of glutei
and obliteration of folds of nates ;
very decided tenderness on pres-
sure over the capsule, in which
there is distinct heat. Cannot lie
on affected side.
Eight months bad ; motion
"awful." Fingers big and swol-
len ; complete circumduction at
hip-joint ; some wasting of hip
and obliteration of folds of nates ;
movements cause aching in leg ;
no tenderness on pressure over the
hip-joint.
Cured, and bad again for last three
weeks. Circumduction at hip-
joint complete ; distinct wasting
of glutei ; came on suddenly and
went off quickly. Left Strath-
peiFer almost quite well.
70. Shoulders very bad ; cured last
year at StrathpefFer. At hip-joint
full flexion distinctly afFected ; in-
ternal and external rotation less so.
APPENDIX II 139
No. Sex. Age.
452. Female. 80. Distinct tenderness over left hip-
joint, none on the right ; exten-
sion distinctly affected. Both hip-
joints bad ; much pain.
453. Male. 35. Some obliteration of folds of nates.
454. Male. 55. No clear history of gout. At hip-
joint circumduction complete ;
marked wasting of glutei and
obliteration of folds of nates ;
tenderness on pressure over cap-
sule ; spasms mostly in thigh.
455. Male. 58. Knee troublesome. At hip-joint
full flexion incomplete, as also
internal rotation ; decided wast-
ing of glutei ; some obliteration of
folds of nates ; distinct tenderness
on pressure over the capsule ; no
tenderness along the course of
sciatic nerve. Began after he got
a kick ; worse after exercise.
456. Male. 55. Wasting of glutei ; some oblitera-
tion of folds of nates ; distinct
tenderness on pressure over the
hip-joint. Slight case ; limp.
457. Male. 42. Complains of rheumatic pains at
hip-joint, also in right shoulder at
times. Full flexion and internal
rotation affected, internal rotation
much more so ; decided wasting
of glutei ; slight obliteration of
folds of nates ; distinct tendernesg
on pressure over the capsule ; great
difficulty in turning in bed, also in
external rotation of leg at hip-joint.
Has had lumbago.
140 SCIATICA: A FRESH STUDY
No.
458.
Sex.
Male.
Age.
65.
459. Female. 60.
460.
461.
Male. —
Male.
40.
462. Female. 43,
463. Male. 65.
Has had lumbago. No power of
circumduction at hip-joint ; some
tenderness on pressure over the
capsule. Case evidently going on
to ankylosis.
Both legs affected ; right circum-
duction complete, left very much
affected ; tenderness on pressure,
decided over capsules of both
legs. Pain vv^orst in left leg when
putting on slipper ; cannot take her
foot out unless she turns her leg
and presses down. Has eczema.
Double case.
Six months ill ; pain only in
morning — his leg chiefly — in thigh
posteriorly as far down as ankle.
Twelve months bad. Circumduc-
tion at hip-joint nearly complete ;
distinct wasting of glutei and
obliteration of folds of nates ; very
decided tenderness on pressure over
the capsule. Has suffered from
renal calculus ; slight case.
Formerly rheumatic ; has had
lumbago. Full flexion and internal
and external rotation at hip-joint
very incomplete ; excessive tender-
ness on pressure over the capsule.
Fifteen months bad ; rheumatism
in hand ; left leg first affected ;
saving it, the right leg got ill.
Began in hip. Has had lumbago.
At hip-joint complete circumduc-
tion ; distinct obliteration of folds
APPENDIX II
141
No.
Sex.
Age.
464. Male. 52.
of nates ; very great tenderness on
pressure over capsule.
Four or five years bad ; difficulty
in getting over fence ; leg occasion-
ally gives way ; has had lumbago.
At hip - joint internal rotation
partly affected ; distinct tenderness
on pressure over the capsule.
Gout in hand. Slight case-
At hip-joint full flexion and in-
ternal rotation incomplete.
Complained of pain in her knee ;
laid up at first, then got better ;
eight months bad ; slight case.
Eight months bad. Wasting of
glutei ; decided tenderness on pres-
sure over hip-joint.
Has had lumbago. Began in back ;
lame, both legs affected. Double
case.
At hip -joint internal rotation
somew^hat affected, external rota-
tion decidedly so. Began on left
side, now on right. Double case.
471. Male. 53. Two years ill; brought on, he
thinks, from sitting on lump of ice.
Loss of power of extension at hip-
joint ; could not sit down for two
days.
465.
Female,
55.
466.
Male.
42.
467.
Female.
40.
468.
Male.
38.
469.
Male.
40.
470. Female. 48.
472. Female. 40.
Pain only in thigh ; almost in-
tolerable ; worse when lying down.
At hip-joint full flexion imperfect ;
142 SCIATICA: A FRESH STUDY
No. Sex. Age.
internal rotation decidedly incom-
plete, external less so ; much wast-
ing of glutei ; great tenderness on
pressure over the capsule.
473. Female. 28. Twelve months ill ; left hip worse
at night when moving the limb.
474. Male. 72. Has had lumbago. At hip-joint
full flexion incomplete ; decided
loss of range of rotation ; external
rotation free, but not full ; distinct
tenderness on pressure over the
capsule ; pain only when walking
or getting into or out of train.
475. Male. 18. Began in groin with swelling,
" result of sneezing " ; not much
pain at night. At hip-joint full
flexion much impaired ; decided
wasting of glutei, and distinct
obliteration of folds of nates ; signs
of pelvic deposit. No history of
gout. Chronic case.
476. Male. 43. A year bad. Has had lumbago ;
some failure in external rotation
at hip-joint ; much tenderness on
pressure in that region. Slight
case.
477. Male. 77. Two years bad. At hip-joint full
flexion incomplete ; internal and
external rotation much more so ;
wasting of glutei, and decided
obliteration of folds of nates, but
no tenderness on pressure over the
capsule. Several attacks. Pelvic
deposits.
APPENDIX II
143
Mo.
Sex.
Age.
478.
Male
53.
479.
Female.
35.
480. Female. 56.
481.
482.
Female. —
Male. .39.
483.
Male.
69.
484.
Male.
71.
485.
Female.
60
486.
Male.
45
Six months bad. Circumduction
at hip-joint unaffected ; distinct
tenderness on pressure over capsule.
A typical case.
One week ill. Doubtful history
of rheumatism. At hip-joint full
flexion interfered with ; no wasting
of glutei ; stiffness and pain when
getting up after sitting some time.
Two months ill. No abnormal
physical sign noted; both sides
affected, left at first ; cannot lie on
the side that is worst. Double
case.
Six months ill. Never had lum-
bago ; limps ; worst at night.
Never had lumbago. Some wasting
of glutei, and slight obliteration of
folds of nates ; decided tenderness
on pressure over capsule of hip-
joint. Second attack. Has to lift
affected leg up when lying down.
Has had lumbago.
Shoulder troublesome ; at hip-joint
full flexion, and external rotation
distinctly hampered.
No notes.
Seven weeks ailing. Two brothers
have had gout. Distinct wasting
of glutei ; marked tenderness on
pressure over the capsule of hip-
joint.
144 SCIATICA: A FRESH STUDY
No.
487.
488.
489.
49:
492,
Sex. Age
Female. 39.
Female. 50.
Male. 61.
Female. 30.
Male. 43.
Male. 20.
493. Female. 29.
Four years ailing. At hip-joint
full flexion affected ; distinct ten-
derness on pressure over capsule ;
stiffness, movements troublesome.
Has had rheumatism. Doubtful if
case is not one of sacro-iliac trouble.
Tw^o months ailing. Distinct
wasting of glutei ; no obliteration
of folds of nates ; no tenderness
on pressure over capsule of hip-
joint. After spa treatment still
lame, and complaining of pain in
the affected leg.
Ten months ailing. Rheumatic
fever when thirteen years of age.
Father rheumatic, brother laid
aside with rheumatism. Pain in
walking from hip to ankle.
Twelve months ailing. Mother
bedridden with gout. Has had
lumbago badly ; distinct wasting
of glutei, and some obliteration of
folds of nates ; decided tenderness
on pressure over the capsule of
hip-joint — slight at first, then very
severe.
Ailing a year and a half. Moderate
wasting of glutei ; decided tender-
ness on pressure over the capsule
of hip-joint. Laid up entirely for
three months.
Ten months ailing. Distinct ten-
derness on pressure over the capsule
of hip-joint ; pain in right hip.
Cured by spa treatment.
APPENDIX II 145
No. Sex. Age.
494. Male. 64. Full internal and external rotation
at hip-joint affected ; distinct ten-
derness on pressure over the capsule
of hip-joint ; pain in hip and down
the front of thigh.
495. Male. 60. Eight weeks ailing. Began in
back, threatened left leg and then
right ; walking causes pain, but
pain also at night ; rheumatism in
shoulder and back ; has had lum-
bago ; circumduction almost com-
plete ; wasting of glutei. Distinct
tenderness on pressure over capsule
of hip-joint, right side.
496. Male, 53. At hip-joint full flexion, and ex-
ternal and internal rotation much
hampered ; decided wasting of
glutei, and obliteration of folds of
nates ; very decided tenderness on
pressure over the capsule. Improved
much by spa treatment.
497. Male. 47. Father and sisters rheumatic ; has
had lumbago. No notes as to
circumduction at hip-joint, probably-
complete ; distinct wasting of glutei,
and obliteration of folds of nates ;
clear evidence of pain on pressure
over the capsule.
498. Male. 68. Has had lumbago; distinct im-
pairment of complete internal
rotation at hip-joint ; some tender-
ness on pressure over the capsule.
Doubtful case, more like sacro-iliac
trouble.
10
146
SCIATICA
No.
499.
Sex. Age.
Male. 38.
500.
501.
Female. 44.
Female. 41.
502.
Male. 63.
503. Female. 54,
504.
505,
Female. 48.
Male. 64.
506. Male. 70.
507. Female. 70.
A FRESH STUDY
Rheumatism of legs and shoulders,
and little lameness. Slight case.
Doubtful case. Pain in hip.
Rheumatism all over. Doubtful
case.
Impairment of full flexion ; de-
cided interference with external
rotation, less with internal rotation
at hip-joint ; wasting of glutei ;
decided tenderness on pressure over
capsule ; pain " ridiculous."
Has had lumbago ; decided wast-
ing of glutei, and some obliteration
of folds of nates ; power of circum-
duction at hip-joint unimpaired ;
distinct tenderness on pressure over
capsule in one leg, and not the
other ; irritation in front of ankle.
At hip-joint flull flexion affected ;
decided tenderness on pressure over
the capsule.
Circumduction complete ; decided
tenderness over capsule of hip-
joint ; pain in walking, limps a
little ; pain in groin, goes down
to his knees.
Pain in full flexion at hip-joint ;.
both external and internal flexion
affected ; much wasting of glutei
and obliteration of folds of nates ;
no tenderness on pressure over the
capsule.
Circumduction of hip-joint com-
plete ; marked tenderness on pres-
sure over capsule.
APPENDIX II 147
No. Sex. Age.
508. Male. 60. Knee been swollen and painful for
a long time ; has had lumbago.
At hip-joint full flexion hampered
(no note about rotation) ; no ten-
derness on pressure over capsule ;
pain in both legs, from hips down-
wards. Slight case.
509. Male. 19. Back of neck and shoulder rheu-
matic ; has had lumbago ; at hip-
joint distinct want of power of
full flexion ; external and internal
rotation distinctly affected ; great
wasting of glutei ; some obliteration
of folds of nates ; decided tender-
ness on pressure over capsule ;
rather lame at first ; uneasy at
night ; both legs bad. Double
case.
510. Male. 45. Has had lumbago. Some impair-
ment of internal rotation at hip-
joint ; pain in hip. Slight case.
511. Male. 53. Has had lumbago. Full flexion at
both hip-joints much impaired ;
both legs bad.
512. Male. 61. Has had lumbago. At hip-joint
external rotation affected ; distinct
tenderness on pressure over the
capsule.
513. Female. 32. Has had lumbago. Right side
now bad ; left nine years ago
affected ; decided tenderness on
pressure over capsule of hip-joint
behind, and to a less extent in
front. Double case.
148 SCIATICA : A FRESH STUDY
No.
5H.
517-
519.
Sex.
Female.
516. Male.
Male.
Male.
Age.
40.
515. Female. 50.
29.
=;o.
518. Female. 51,
67.
520. Male. 69.
Rheumatism in elbow and both
feet, and lumbago. Very decided
tenderness on pressure over the
capsule of hip-joint.
At hip-joint pain and hampering
of full flexion ; marked tenderness
on pressure over the capsule ; can-
not cross her legs ; difficulty in
getting into an upright position.
Three years ill ; rheumatism in
shoulder and all over body. Much
wasting of glutei, and marked
tenderness on pressure over capsule
of hip-joint.
Has had lumbago ; six years ailing.
Much wasting of glutei and
obliteration of folds of nates ;
decided tenderness on pressure over
capsule of hip-joint, with distinct
heat locally.
Circumduction complete; tender-
ness on pressure over capsule of
hip-joint ; both knees rheumatic.
Has had lumbago. At hip-joint
full flexion inadequate, external
rotation more so. Other signs not
recorded.
Right shoulder troublesome ; at
hip-joint circumduction complete ;
decided wasting of glutei and
obliteration of folds of nates ; has
also much tenderness on pressure
over the capsule ; pain from hip to
knee.
APPENDIX II
49
No.
521.
Sex.
Female.
Age
52.
522. Male. 22.
523. Female. 29,
524. Male. 43.
525, Male.
526.
65.
Ill for a month ; much rheumatism.
Circumduction at hip-joint dis-
tinctly hampered ; no tenderness
on pressure over the capsule. She
feels her right hip much when she
gets up ; gets bad in bed.
Rather troubled with lumbago-
Full flexion and external rotation
at hip-joint distinctly affected ;
some wasting of glutei, and very
decided tenderness on pressure over
the capsule.
Six months ailing ; began in her
back. At hip-joint full flexion and
external rotation hampered and
painful ; considerable wasting of
glutei and obliteration of folds of
nates, also marked tenderness on
pressure over the capsule. Limp ;
difficulty in putting on stocking ;
pain worse on standing up.
Distinct obliteration of folds of
nates ; decided tenderness on pres-
sure over capsule of hip-joint ; could
not lie in bed ; difficulty in turning
when recumbent. Second attack.
Merely a little stiffness ; slight
case ; had severe sciatica some
years ago.
Ailing for six years. At hip-joint
external and internal rotation
decidedly interfered with ; no
tenderness on pressure over the
capsule. Slight case.
I50 SCIATICA: A FRESH STUDY
No. Sex. Age.
527. — — Two years bad ; some trouble in
back two years ago. At hip-joint
full flexion incomplete ; some
wasting of glutei, and distinct
obliteration of folds of nates ; quite
definite tenderness on pressure over
the capsule. Slight case ; cured
by spa treatment.
528. Female. 40. Ten weeks in bed ; father had
sciatica. At hip-joint full flexion
incomplete ; external rotation
much affected, internal less so 5
distinct wasting of glutei ; acute
tenderness on pressure over cap-
sule. Very severe case ; no im-
provement by spa treatment.
529. Male. 51. Rheumatic; generally pained after
much exertion ; lumbago once.
At hip-joint distinct impairment
of external and internal rotation,
with wasting of glutei and oblitera-
tion of folds of nates ; decided
tenderness on pressure over the
capsule.
530. Male. 51. Joints of fingers and toes enlarged ;
at hip-joint definite interference
with internal rotation. No other
notes.
531. Male. 57. Three months ailing nine years
ago. Rheumatism in left arm ; at
hip-joint marked diflRculty in in-
ternal rotation, also wasting of
glutei and obliteration of folds of
nates ; very decided tenderness on
pressure over capsule.
APPENDIX II
ici
No.
532.
Sex.
Female.
Age.
45-
533. Male. 49.
534. Female. 72.
535. Male. 53.
Two or three ^months ailing ; four
weeks in bed. At hip-joint full
flexion decidedly impaired ; no
interference with external and in-
ternal rotation ; marked tenderness
on pressure over capsule. Fourteen
years ago pain after confinement,
now pain on crossing her legs, and
when tired.
At hip-joint distinct impairment
of full flexion ; internal rotation
also aflfected ; much wasting of
glutei, with distinct tenderness on
pressure over capsule ; now pain in
moving leg when tired out.
Heberden's nodes ; pains in toe-
joints ; distinct impairment of full
flexion at hip-joint, also of external
and internal rotation, with much
pain in all three movements ;
tenderness on pressure over right
capsule ; pain worse after sitting
down. Not bad at night ; began
in hip, and then went to knee ;
cannot cross her legs. Double
case.
Has had rheumatism in shoulder ;
at hip-joint full flexion impaired,
external rotation decidedly so, also
internal ; decided wasting of glutei,
and considerable obliteration of
folds of nates ; no tenderness on
pressure over the capsule ; slight
lameness ; pain when standing,
occasionally also in bed and in
crossing his legs.
152 SCIATICA: A FRESH STUDY
No. Sex. Age.
536. Male. 66, Has had lumbago. At hip-joint
some trouble in full flexion, none
in external or internal rotation ;
decided pain on pressure over cap-
sule ; some pain in shoulder (renal
calculus).
537. Male. 50. Six years ailing ; has had lumbago.
Some wasting of glutei, and con-
siderable obliteration of folds of
nates ; decided tenderness on pres-
sure over the capsule.
538. Male. 66. Six months ailing. Some pain in
arm and hand ; great pain in leg,
with swelling of the limb ; quite
lame ; at hip-joint circumduction
slightly interfered with ; much
wasting of glutei, and considerable
obliteration of folds of nates ; very
decided tenderness on pressure over
the capsule.
539. Male. 40. Two weeks bad ; mending before
came to Strathpeffer. Distinct
wasting of glutei ; no tenderness
on pressure over the capsule of
joint. Slight case — taken early.
540. Male. 61. First attack three years ago ; has
had lumbago. Circumduction
nearly complete ; decided wasting
of glutei and some obliteration of
folds of nates ; no tenderness on
pressure over capsule.
541. Male. 56. Ailing for seven months ; golf
started the trouble. Pain in getting
up ; pain on blowing his nose ;
pain runs down left side to knee,
APPENDIX II 153
No. Sex.
and below it ; circumduction com-
plete. Began in hip ; slight case ;
cured.
542. Male. 65. At hip-joint circumduction com-
plete ; distinct tenderness on pres-
sure over the capsule ; toe-joints
occasionally red and inflamed ;
easier when clothes on,
543. Female. 46. Ten months ailing. At hip-joint
full flexion hampered, as also, but
more so, external and internal
rotation ; distinct wasting of glutei
and obliteration of folds of nates ;
marked tenderness on pressure over
the capsule. Very severe at first ;
began in hip, and then went to
the leg ; quite lame.
544. Male. 32. Two months ailing. Mother rheu-
matic. Circumduction complete ;
, decided wasting of glutei, and
obliteration of folds of nates ; ten-
derness on pressure over capsule,
fairly well marked ; no tenderness
along the course of sciatic nerve ;
coughing causes pain in hip and
down the outside of leg.
545. — — Three months in bed. No rheu-
matism hereditarily ; has had lum-
bago. Distinct wasting of glutei,
and obliteration of folds of nates ;
well-marked tenderness on pressure
over the capsule. Two attacks of
sciatica when young. Difficulty
in turning when lying down ;
pain began first in hip ; no tender-
ness along the course of sciatic nerve.
154 SCIATICA: A FRESH STUDY
No.
546.
547.
Sex.
Male.
Age.
60.
548. Female. 42.
549. Female. 50.
Very mild case.
— 60. Rheumatism two or three years
ago. Pain first in right arm, now
in left hand ; pain comes on sud-
denly ; lame ; at hip-joint full
flexion, also external and internal
rotation much affected ; decided
wasting of glutei ; distinct tender-
ness on pressure over the capsule.
Ankylosis threatening.
Brother has had sciatica. Circum-
duction hampered. Mild case.
First in right and then in left leg ;
pain does not extend below the
knees ; has to get up and rub her
leg at night ; slight limp ; distinct
tenderness on pressure over the
capsule of the joint ; obliteration
of folds of nates.
550' — — Strong case ; has had lumbago.
At hip-joint full flexion markedly
incomplete, external rotation less
so, and internal free ; much wast-
ing of glutei, and obliteration of
folds of nates ; marked tenderness
on pressure over the capsule, which
shows local heat and distinct swell-
ing. Improved with spa treatment.
Full doses of salicylate of soda did
good. Double case.
551. Female. 55. Eighteen months ailing; has had
lumbago. Decided tenderness on
pressure over capsule of hip-joint;
began in the bone of right leg,
APPENDIX II
^55
No.
Sex. Age.
552. Female. 55.
553.
Male.
555.
556.
Male.
Male.
36.
554. Female. 60.
53.
56.
557. Female. 57.
558. Male. 70.
" went up in a nerve " ; could
not cough without pain ; walking
causes pain. Eight months in bed.
Six months ailing ; has had lum-
bago. Lame ; could not stand
straight up ; worse when walking
about.
Five years bad ; has had rheu-
matism and lumbago. Some wast-
ing of glutei, and obliteration of
folds of nates ; decided tenderness
on pressure over capsule of hip-
joint, with distinct swelling and
heat.
First attack fifteen years ago ;
second has lasted for a year ; has
had lumbago. Hands and feet
some swelling. Mild case.
Two years bad ; has had lumbago.
Some pain in hand. Mild case.
Rheumatism in shoulder ; external
rotation at hip-joint affected ; some
tenderness on pressure over capsule.
Slight case.
Eight months ailing. At hip-joint
external rotation affected ; decided
tenderness on pressure over capsule
of hip-joint ; began with pain in
stooping ; all right when lying
down, but could not turn her body.
Double case.
Attack seven years ago, bad for
nine months at this time. At hip-
joint full flexion decidedly incom-
156 SCIATICA: A FRESH STUDY
No. Sex.
Ag£
559. Male.
560. Male.
561. Female.
68.
61
35.
562 Male. 40.
563.
Female.
70,
564.
Male.
61
565.
Male.
73<
plete, external rotation more so,
internal rotation less ; very decided
tenderness on pressure over capsule ;
lame until warm weather ; first
attack left leg, now right ; ankylosis
beginning. Double case.
Rheumatism in a.rm. At hip-joint
full flexion affected, as also external
and internal rotation ; began in
hip ; cannot lift one leg over the
other ; no tenderness on pressure
over capsule ; apparently going on
to ankylosis.
At hip-joint both external and
internal rotation much affected ;
history of syphilis.
Flexion at hip-joint hampered,
external rotation much more so ;
excessive tenderness on pressure
over the capsule of hip-joint.
Has had lumbago. At hip-joint
full flexion and external rotation
complete ; had pain in peroneal
region, and numbness ; pain in one
groin and then another ; sudden
attack below knee.
Decided tenderness on pressure
over the capsule of hip-joint ; pain
usually in bed. Slight case.
Rheumatism in both legs ; at hip-
joint full flexion complete ; internal
rotation affected, external more so ;
distinct tenderness over the capsule.
Fourteen months ailing. Pain in
shoulder ; lumbago.
APPENDIX II 157
No. Sex. Age.
566. Male. 65. Pain in heel ; difficulty in straighten-
ing himself up and tying bootlaces ;
at hip-joints some trouble in full
flexion ; distinct difficulty in both
legs in external rotation ; trouble
in both legs in internal rotation.
Double case.
567. Male. 54. Rheumatism in both shoulders ; at
hip-joint imperfection in full flexion,
and internal rotation ; obliteration
to some extent of folds of nates ;
heat and swelling of right capsule ;
left threatening ankylosis. Im-
proved by massage. Double case.
568. Male, 63. Has had lumbago. At hip-joint
some hampering of movement of
full flexion ; external rotation much
aflfected ; distinct wasting of glutei ;
obliteration of folds of nates, and
, decided tenderness on pressure over
the capsule. Slight case. Cured
by spa treatment.
569. Male. 62. Circumduction perfect ; no tender-
ness on pressure over capsule of
hip -joint. Slight case. Left
Strathpeffer cured.
570. Female. 65. Slight case.
571. Female. 65. Six months ailing. At hip-ioint
full external rotation distinctly
affected ; decided tenderness on
pressure over the capsule. Im-
proved with spa treatment.
572. Male. 42. Both shoulders rheumatic ; distinct
tenderness on pressure over capsule
of hip-joint.
158 SCIATICA: A FRESH STUDY
No. Sex. Age.
573. Male. 45. Three months ailing. At hip-joint
circumduction complete ; wasting
of glutei ; distinct tenderness on
pressure over capsule.
574. Male. 53. Nine months ailing; bad four years
ago ; worst in the morning ; rest
relieves pain ; quite lame. Cir-
cumduction almost quite incom-
plete ; some wasting of glutei, and
distinct obliteration of folds of
nates ; no tenderness on pressure
over the capsule ; ankylosis evi-
dently threatening. Double case.
575. Male. 38. Some months ill ; has had lumbago.
At hip-joint external and internal
rotation imperfect, considerable
pain with former ; some wasting
of glutei, and very decided obliter-
ation of folds of nates. Chronic
case. Pained at first during the
night, now through the day, but
all right when he walks about.
Took as much as 120 grains of
salicylate of soda without any bad
effect.
576. Male. 58. Three months ailing. At hip-joint
full flexion somewhat hampered ;
distinct obliteration of folds of
nates ; no evident wasting of glutei ;
marked tenderness on pressure over
the capsule ; lame ; double sciatica.
577. Male. 45. Worst in the morning. Rest re-
lieves.
578. Male. 51. Second attack; has had lumbago.
At hip-joint full flexion, and ex-
APPENDIX II
H9
No.
Sex.
Age.
579. Female. 60.
580. Female. 52.
581. Male. 52.
582, Female.
583. Male. 60.
ternal rotation much affected,
internal rotation less so; some
wasting of glutei, and obliteration
of folds of nates; decided tender
ness on pressure over the capsule
Began in peroneal region of leg
went upon last occasion to hip
easier in bed ; lame last summer ;
pain occasionally pulls him up
when walking.
At hip-joint decided interference,
with full internal rotation ; marked
tenderness in front of capsule, less
behind, but extending down the
course of the sciatic nerve.
Has had lumbago. At hip-joint
full flexion, and external rotation
much interfered with ; extension
also hampered distinctly. Cannot
lie on left side ; easier when walk-
ing about. No note as to tender-
ness over the capsule.
Was ill seven or eight years ago ;
began as neuritis of spine ; aspirin
relieves his pain.
Twenty months ill. At hip-joint
external and internal rotation
decidedly hampered ; distinct wast-
ing of glutei ; marked tenderness
on pressure over the capsule ; acute
case relieved by aspirin.
Attack eighteen years ago. Cir-
cumduction complete ; distinct
tenderness on pressure over the
capsule of hip-joint. Slight case.
i6o SCIATICA: A FRESH STUDY
No. Sex. Age.
584. Male. 29. Says he has been ill for two years.
At the hip-joint much pain in
flexion and external rotation ;
decided obliteration of folds of
nates ; marked tenderness on pres-
sure over capsule, with decided
heat and sense of fluctuation in
that region. Doubtful at the time
if it was a case of ordinary sciatica,
but by-and-by the patient got to be
quite well
58$, Male. 68. Three months ill; has had lum-
bago. At hip-joint full flexion and
external rotation distinctly affected ;
marked tenderness on pressure over
the capsule ; pain in turning in
recumbent position, also in sneez-
ing. Cannot ride, but can play
golf.
586. Female. 40. No interference with full flexion
and internal rotation, but external
rotation decidedly hampered ; ex-
tension all right ; began in hip.
587. Female. 47. Twelve months aihng. At hip-
joint full flexion ; external and in-
ternal rotation decidedly interfered
with ; both legs been bad, now
only in right. Double case.
Male. 45. Ill for some weeks. Pain and
interference with internal rotation ;
marked pain on pressure over the
capsule of hip-joint ; much relieved
by very hot sulphur baths ; only
a little pain down the back of
affected leg.
APPENDIX II
i6
No. Sex.
589. Male.
590. Male.
591. Female.
592. Male.
Age.
11-
70.
593. Female. 40.
594. Male. 65.
History of gout ; much improved
after spa treatment. Double case.
Slight case.
Some pain on internal rotation at
hip-joint. Doubtful case.
Four months ailing. At hip-joint
full flexion hampered ; external
and internal rotation decidedly
affected ; distinct wasting of glutei
and obliteration of folds of nates ;
some tenderness on pressure over
capsule ; no pain along the course
of sciatic nerve.
Shoulder troublesome ; at hip-joint
full flexion decidedly affected, ex-
ternal rotation more so, but in-
ternal rotation quite free ; distinct
obliteration of folds of nates, and
decided tenderness on pressure over
the capsule.
An attack two or three years ago ;
present seizure has lasted about six
months; has had lumbago. At
hip-joint full flexion, external and
internal rotation distinctly affected ;
decided tenderness on pressure over
the capsule ; limps a little ; pain
bad in bed at first, now when
walking about.
595.
Male.
11-
Slight case.
596.
Male.
70.
Double case.
597.
Male.
59-
Ailing five years. Arms rheu-
matic ; pains at hip-joint ; full
flexion decidedly affected, as also
1 62 SCIATICA: A FRESH STUDY
No.
Sex. Age.
598. Male. 62.
599.
600.
Female.
Female. 57.
601,
602.
603.
Female. 40.
Male. 63.
Female. 71.
internal rotation, but external quite
free ; marked tenderness on pres-
sure over the capsule ; right leg
now bad, left to begin with ; pain
now in walking, and limps a little.
Double case.
Father had gout ; doubtful history
of lumbago. At hip-joint circum-
duction much hampered ; marked
tenderness on pressure over cap-
sule ; right leg affected — began in
left, starting in knee and going up
to hip ; cannot straighten himself.
Double case.
Four months ailing. At hip-joint
circumduction almost nil ; quite
lame.
Three months ill four years ago ;
was bad ; knee troubled and has
had lumbago. Difficulty in turn-
ing in bed when very bad ; cannot
stand on her legs ; distinct tender-
ness on pressure over capsule of
hip-joint.
Difficult to say which leg affected ;
walking brings on pain in knee ;
bad heart.
Seven months ailing ; never had
gout or rheumatism ; has had lum-
bago ; easier in bed.
Three years ailing ; has had lum-
bago. Doubtful which side affected ;
some limp ; began in hips, now in
toes.
APPENDIX II
163
No.
Sex.
Age.
604.
Male.
33.
605.
Male.
60.
606. Male. 46.
607. — —
608. Male.
76.
609.
610.
Female.
Female.
66.
74.
Mild case.
Has had lumbago. Decided wasting
of glutei ; obliteration of folds of
nates ; marked tenderness on pres-
sure over the capsule of hip-joint.
Three months ill ; has had lum-
bago. Difficulty in deciding which
leg affected ; has trouble in cross-
ing his legs or in standing in up-
right position.
Previous attack ten years ago ; has
had lumbago. At hip-joint ex-
ternal and internal rotation entirely
stopped in both legs ; wasting of
glutei ; distinct obliteration of folds
of nates ; cannot walk without
two sticks. Ankylosis beginning.
Double case.
Fifteen months ailing ; began two
years ago ; father gouty. Began
with lumbago ; could not ride or
walk ; pain in thigh and outside of
leg ; laid up for a month at a
time.
Marked tenderness on pressure
over the capsule of hip-joint.
At hip-joints full flexion much
restricted, external rotation less,
and internal more so ; decided
tenderness on pressure over both
capsules ; difficulty of getting into
bed and in crossing her legs ;
doubtful which leg affected.
Double case.
1 64 SCIATICA: A FRESH STUDY
No.
6ii,
Sex.
Male.
Age.
58.
612. Male. 26.
Fifteen months ailing ; ill four
years ago. At hip-joint internal
rotation decidedly affected, and
causes great pain ; extension com-
plete ; left leg first affected, now
the right ; cannot stand ; pain in
peroneal region of leg.
Cannot walk without two sticks.
Cannot ride. Laid up for a
month. Has had two to three
attacks.
613.
Female.
66.
Much tenderness on pressure over
the capsule.
614.
Female.
74.
No notes.
615.
Male.
58.
Some impairment and pain on
internal rotation.
616. Male. 58. He had acute rheumatism four
times. Both legs affected. Right
flexion. Left internal rotation.
Last year, neuritis left leg ; neu-
ralgia trigeminal ? persistent ; this
year, pain in sciatic nerve ; limp ;
could not cross his legs.
Sudden attack of pain and weakness
in her legs ; has had sciatica and
acute gout.
Male. 50 Difficulty in standing erect ; no
local sign.
Female. — Rheumatism in both legs ; diffi-
culty in turning in bed ; worst at
night, also stiff and lame when
walking ; pain in both knees, but
not lower down. Double case.
617. Male. 60.
618. Female. 63.
619.
620.
APPENDIX II
i6s
No. Sex. Age.
621. Male. —
622. Female. 47.
623. Female. 23.
624. Female. —
625. Male. 67.
626. Male. —
627. Male. 45.
628. Female. —
629. Male. 36.
Pain coming downhill "jumps";
much enlargement of left tro-
chanter.
Occasional pain in leg, and in
right foot.
Acute attack. Right side better,
then, after a fall, as bad as ever.
Much wasting of glutei and oblite-
ration of folds of nates. Great
tenderness on pressure over the
capsule.
Left leg worst in bed ; began in
hip ; right formerly not so bad
in moving about. Double case.
Left leg, ankle, and peroneal region ;
must be walking ; difficulty in
putting on stocking ; coughing
aggravates ; no tenderness over
sciatic nerve.
Left leg, pain in spring; difficulty
in getting up and down, and turn-
ing in bed ; lame. Slight case.
Calculus of left ureter.
Lame ; worse during the day ;
no tenderness along sciatic nerve.
Both legs, worst in right; rheu-
matism in muscles ; getting worse.
Double case.
Both legs, left worst when walk-
ing ; limp ; coughing and sneezing
affects it ; knee extended and raised
causes pain ; both sides ; cannot
stoop. Double case.
1 66 SCIATICA: A FRESH STUDY
No,
630.
632.
633-
Sex.
Female.
Age.
36.
631. Female. 35.
Female.
Lame; walking hurts; difficulty
in getting in and out of bed; could
not cross her legs; stooping diffi-
cult ; right side affiscted.
Both sides, at first at night, now
when moving about; difficulty in
turning in bed, and going upstairs,
and putting off and on shoes.
Double case.
59. Pain in peroneal region; worst
when walking ; left side affected ;
shoulder also affected. Slight case.
Female. 53.
634. Female. 62.
635. Male. 64.
636. Male. 44.
Rheumatism in feet and hands ;
some difficulty in straightening
herself; circumduction; external
rotation distinctly affected; flexion;
tenderness ; pressure well marked.
Lumbago and sciatica ; neuritis in
left arm, been also in right ;
sciatica in both legs, easy when
lying down ; in left tenderness
very considerable ; slight internal
rotation ; distinctly improved right
circumduction.
Rheumatism in left leg ; occasional
lameness catches him in thigh ;
not troubled at night; shoulder,
deltoid, and biceps.
Slight sciatica, and lameness on
right side ; stiffness mostly in hip ;
turning in bed affects it; slight
pain on external rotation ; no
tenderness on pressure over the
capsule of hip-joint.
APPENDIX II
167
No.
637.
Sex. Age.
Male. -—
638. Male. 51,
639. Male. 65.
640. Female. 59.
641. Female. 59.
642. Male.
Seen with Dr. Mowat ; history of
attack of lumbago three weeks
ago, followed shortly by sciatica
on left side ; cannot walk for pain,
which was also bad at night, and
required hyp.
Lumbago attack a year ago, then
better, walked too much ; back
and legs not examined ; this spring
very bad; at present can hardly
walk at all ; much pain in left leg
when turning.
Two years ago began in left leg ;
tired when travelling, limps, worse
about midnight ; difficulty in turn-
ing in bed, worse in getting up ;
pain in knee, in front, not in ankle ;
fastening shoe impossible.
Came on seventeen years ago,
after her confinement ; could not
stand, weaker and weaker, limp ;
no pain when sitting, or by night,
only when she moves about ; cir-
cumduction complete; tenderness
on pressure over capsule well
mxarked.
Right leg; began two years ago;
bad at one time in bed. Now when
walking, coughing, and sneezing
does not affect her ; first in thigh,
and then hip ; difficulty in turning
in bed ; could not cross her legs.
Annual attacks; coughing and
sneezing hurt ; sudden seizure.
1 68 SCIATICA: A FRESH STUDY
No.
643'
650.
651.
653.
654.
Sex.
Male.
Age.
644.
645.
646.
Male.
Male.
Female.
31-
49<
647.
Female.
38.
648.
Male.
72.
649. Male. 52.
Female.
Female.
652. Male. 61.
Female.
Male.
30.
Both groins ; difficulty in putting
foot beneath him, also in turnipg
in bed; worst with exertion and
stooping ; uneasiness in sitting
down ; no pain below knee.
Double case.
No notes.
Sudden attack in hip.
Sciatica began in the leg ; worse
after a long walk.
Right side affected ; difficulty in
turning in bed ; sharp pain when
moving.
Came on after a wetting; worse
at night when hot, but now when
walking pulls him up suddenly ;
limps ; pain from hip downwards ;
" fiery darts " below knee.
Pain in outside of leg, also hip
and groin.
Pam on putting on stocking.
After accident in hansom ; diffi-
culty in turning.
Left side affected ; sudden attack ;
never quite gone ; at first difficulty
in turning in bed ; could not ride ;
slight limp ; tenderness on pressure
over capsule.
Right leg ; limp. Slight case.
Pain from hip to knee ; cannot cross
his legs ; began in heel ; coughing
and sneezing hurts him ; difficulty
in going upstairs ; worse when
walking.
APPENDIX II
169
No.
Sex.
Age
655.
Male.
656.
Male.
58.
657.
Female.
—
658.
Male.
61.
659.
Female.
30-
660.
Male.
69.
661. Male. —
662. Female. 56.
663. Female. 45,
664. Female.
Left ; pain on the inside of lower
edges of buttock ; spine twisted ;
great difficulty in turning in bed.
Pain outside of leg, also in hip and
loins.
After accident in hansom, difficulty
in turning in bed.
Sudden attack ; pain never quite
gone ; at first difficulty in turning
in bed ; slight limp.
Right leg ; limp ; slight case.
Pain from hip to knee; began in
legs ; coughing and sneezing hurt ;
difficulty in going upstairs; worst
when walking.
Left leg; pain in the inside of
thigh and lower edge of buttock;
spine twisted ; great difficulty in
turning in bed.
Right leg bad for two years ; began
in haunch ; walking or anything
she strikes with her toe brings on
pain ; sometimes bad at night ; can-
not lie on affected side ; some limp.
Complains of pain down left side ;
sciatica came on acutely in Nairn,
though lame before she left home ;
the attack confined her to bed.
"Rheumatism" in hip-joint; be-
gan in July, and kept on during
the winter, worse since May ;
comfortable in bed ; pain down
both legs; difficulty in getting up
and turning.
170 SCIATICA: A FRESH STUDY
No.
665.
666.
667.
668.
669.
Female.
Female.
Male.
Female.
Female.
670.
Male.
671.
Female.
672.
Male.
673.
Female.
26.
45.
39-
54.
60.
674. Female. 52,
Age.
55. "Rheumatism" at top of right
thigh ; slight limp ; pain worse at
night ; acute pain in arms, and
also between shoulders.
54. Double sciatica.
Left leg gets hot with much
walking, with prickly feeling down
outside, and heat; cannot shift from
side to side when in bed.
Pain in hip ; ankles swelled a little ;
knee also been swollen.
Lame right side ; fall sprained her
back ; got quite right as far as
back was concerned, but a sharp
pain across right thigh ; bad at
night, but better on moving ; great
difficulty in getting into and out
of bed.
Right leg affected ; began in
haunch; sleepless; middle joints
of fingers swollen, also toe-joints.
Sciatica left leg ; lame ; walking
and standing brings it on, all right
when resting. Both wrists aiFected.
Sciatica began in haunch ; diffi-
culty in moving affected leg.
Sciatica in right leg ; lame ; diffi-
culty in putting right leg over
left ; shoulder also troublesome.
Pain in knees, mostly at night,
not so much when on her legs ;
left knee a little swollen.
APPENDIX II
171
No.
675.
677.
678,
683.
684.
Sex.
Female.
Male.
Male.
Female.
Female.
Age.
46.
676. Male. 52.
62.
36.
679.
Female.
62.
680.
Male.
73-
681.
Male.
77-
682.
Female.
78.
41
Pain in right hand gone, but can-
not lift a spoon ; began in calf of
leg, then went up to hip ; lame ;
cannot lift affected leg over the
other, easiest when stretched out.
"Rheumatism" in ankles, comes
and goes ; stiffness in thighs ;
difficulty in putting one leg over
the other; also pain in back of
left shoulder, cannot lie on that
side.
Has had slight sciatica — better ;
pain in region of groin.
" Rheumatism " in small of his
back, then down the hip ; slightly
lame; worse when working ; better
in winter, worse in spring ; cough
hurts him.
"Rheumatism"; all right when
in California.
Sciatica fifteen years ago; cured
for ten years ; worse when going
about ; occasionally bad at night.
"Rheumatism" in right hip and
knee, also in left.
Difficulty in breathing ; pain in
back ; sciatica on right side ; pain
in left knee ; heart weak ; feet
swelling.
Trouble in right side; walking
hurts her.
Accident, fell back on right but-
tock, had a cold at the time ;
slight pain when she moved about.
172 SCIATICA: A FRESH STUDY
No. Sex.
685. Male.
Age.
51.
686. Male. 65.
687. Male. 64.
688. Female. 59.
689. Male. 44.
690. Female. 30.
Lumbago a year ago ; much pain
in left leg when turning in bed ;
can scarcely walk at all ; pain
began in neck. Double sciatica.
Two years ago began in left leg ;
worse about midnight ; difficulty
in turning in bed ; no anaethesia
or spasms; fastening shoe impos-
sible; joint quite ankylosed; flexion
bad ; internal rotation imperfect ;
wasting of glutei considerable ; so
also obliteration of folds ; much
tenderness on pressure at upper
part of capsule of hip-joint.
" Rheumatism " in left leg ; occa-
sional lameness catches him in the
thigh ; not bad at night ; rheu-
matism in shoulder; wasting of
glutei decided ; also obliteration
of folds; internal rotation much
affected ; great stiffness.
Limp ; no pain when resting, only
when she moves about ; consider-
able tenderness on pressure over the
capsule ; circumduction all right.
Slight sciatica and lumbago on
right side ; stiffness on moving,
mostly in hip ; turning in bed
affects him severely.
Double sciatica, right the worse ;
circumduction somewhat impaired;
slight wasting of glutei ; also ob-
literation of folds of nates ; tender-
ness on pressure over capsule
considerable.
APPENDIX II 173
No. Sex. Age.
691. Male. 55. Circumduction, flexion, and inter-
nal rotation somewhat impaired,
extension more so ; winces notice-
ably with strong pressure over the
upper and back part of the capsule
of left hip-joint ; wasting of glutei
considerable, also obliteration of
folds of nates; no tenderness on
pressure over the course of the
sciatic nerve.
BIBLIOGRAPHY
GowERs : " Sciatica," Manual of Diseases of the Nervous
System, third edition, 1889, vol. i., p. lOi.
Henry Lawson, M.D. : Sciatica, Lumbago, and Brachi-
algia. Churchill. 1877.
Dr. Fuller : Rheumatism, Rheumatic Gout, and
Sciatica, i860.
Handfield Jones, F.R.S. : Studies in Functional Nerve
Disorders. (Mentions flattening of hip. Does not
believe, for anatomical reasons, in ovarian and uterine
tumours causing pressure on sciatic nerve ; nor
that retained faeces is a likely cause of sciatica.)
Churchill, 1870,
J C. Renton : Sciatica and its Surgical Treatment.
Royal Society, May 12, 1908.
Wilson : " The Sciatic Nerves," Handbook of Medical
Diagnosis. 1909.
BowLBY : " On Pain," The Clinical Journal, February 24,
1904.
Harburn : " Some Points on the Treatment of Brachi-
algia and Sciatica," Medical Press and Circular,
September 28, 1904.
Dr. Bela Bosanye : " Sciatica," Lancet, November 24,
1906, p. 1472.
Dr. Brindley James: "Sciatica and its Treatment,"
British Medical Journal, October 10, 1908.
174
BIBLIOGRAPHY 175
Alfred Gordon, M.D., Philadelphia : " Radicular
Sciatica," Journal of the American Medical Associa-
tion, March 26, 1910.
A, Symon Eccles, M.B., etc. : Sciatica. Macmillan,
1893-
Dr. James Mackenzie : "Pain," Brain, vol. xxv., p. 308.
Harris : " Diagnosis and Treatment of Sciatica," Clinical
Journal, January 13, 1909.
Forbes Ross: "Sciatica," Lancet, January 11, 1906,
p. 89.
Gordon : " Sciatic Neuralgia," Diseases of the Nervous
System. 1908.
Shoemaker : " Sciatica," Monthly Cyclopedia and
Medical Bulletin, Philadelphia, July, 1909.
Goldthwait : " Note on Sciatica," The Hospital,
December 11, 1909.
Aldren Turner and Grainger Stewart : Textbook
of Nervous Diseases. 19 10.
Frank Fowler : " Sciatica," Practitioner, 1907,
vol. Ixxviii., p. 410.
Verebely : " Pathology of Sciatica," Lancet, March 2,
1907.
Bruce W. J. Ironside : " The Relation between Sciatica
and Disease of the Hip-joint," The Practitioner,
April, 1908.
Stockman and Goadby : Lancet, April 13, 191 3.
BaillUre, Tindail and Cox, 8, Henrietta Street, Cox'ent Garden, London,
PLATE IV.
FIG. I. — ARTHRI'ilS DEFORMANS. NORMAL JOINT
FIG. 2. — ARTHRITIS DEFORMANS. AFFECTED JOINT
PLATE V.
FIG. I.— CASE OF T. L. NORMAL JOINT
FIG. 2.— CASE OF T. L. AFFECTED JOINT
PLATE VI.
FIG. I.— CASE OF J. D. NORMAL JOINT
FIG. 2.— CASE OF J. D. AFFECTED JOINT
PLATE VII.
FIG. I.— CASE OF M. H. NORMAL JOINT
FIG. 2. — CASE OF M. H. AFFECTED JOINT
PLATE VIII.
FIG. I.— CASE OF MISS S. NORMAL JOINT
FIG. 2. — CASE OF MISS S. AFFECTED JOINT
PLATE IX,
^m^ -. -->%*>->»-.. -'
\
^^
WASTING OF RIGHT HIP
PLATE X.
,,.-^,^^^^
WASTING OF RIGHT HIP
PLATE XI.
IHF
^ ' ■.,
r
■i:''-'^'^^''
"*"'"'^^^^.*-;«^
'
1
\
-1
WASTING OF RIGHT HIP
PLATE XII.
WASTING OF RIGHT HIP
PLATE XIII.
WASTING OF RIGHT HIP
PLATE XIV.
WASTING OF RIGHT HIP
PLATE XV.
FLATTENING OF RIGHT HIP
PLATE XVI.
WASTING OF LEFT HIP
PLATE XVII
WASTING OF LEFT HIP
PLATE XVIII.
WASTING OF LEFT HIP
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